"First Call" Minimizes
by Karen L. Andalman McIntyre
"Workers Compensation." It's a term that alarms many employers. And it's
no wonder. Consider these statistics:
- On an average day in the United States 17,000 workers are injured, costing
the economy more than $110 billion a year.
- A total of 5.2 million injuries and illnesses were reported in private
industry workplaces during 2001, resulting in a rate of 5.7 cases per 100
equivalent full-time workers, according to a survey by the Bureau of Labor
Statistics. Of the 5.2 million total injuries and illnesses, roughly 2.6
million required recuperation away from work or restricted duties at work.
- Average workers' compensation insurance premiums and other costs run
2-3 percent of payroll, and in extreme cases can equal as much as 80 percent
While these statistics may be alarming, taking control of your workers
compensation program can cut annual direct costs by 25 percent to 50 percent.
The most effective way to take control of your program is to implement a "First
Call" claim management reporting system, which directs employees towards care
at the initial point of the claim.
Here's why it is so effective:
- Promotes communication between all parties involved. This is really
the key to a successful program. A "First Call" program promotes communication
between the injured employee, the employer, the provider of the medical services
and the nurse case manager. As soon as the injured employee makes this first
call to the nurse case manager, the nurse case manager becomes the hub of
the three-point contact, coordinating the services and communication between
- Directs the injured worker to the appropriate provider of services.
From the initial call, the nurse case manager only directs the injured employee
to quality providers and often negotiates discounts for services. This circumvents
the patient just going to an internist or general practitioner when the proper
specialist can be seen from the onset. Expediting expert treatment cuts costs
by making sure the injury isn't aggravated or worsened and by eliminating
unnecessary doctor visits.
- Gives the injured worker a nurse advocate. The assigned nurse
case manager works one-on-one with the injured employee throughout the case
--- from first call through return to work --- to make sure he is getting
the best care possible. Throughout the case she is continually following
up with the injured employee to make sure they are following the treatment
plan, doctor's orders, taking prescribed medications and going to physical
therapy, if ordered. The nurse case manager can also interpret the physician's
orders to the patient.
- Assures parties involved that the process is positive. Because
there is a nurse advocate assigned to the case, adversarial relationships
between the employer, injured employee and physicians do not arise. The employer
is assured that the employee is doing everything to take care of the injury
and return to work as soon as possible. The employee feels that the employer
cares and that they are receiving appropriate care. And, physicians get a
timely response for approval to render services.
- Guarantees a quicker return to work thus saving money on disability
payments. We have found that a "First Call" program closes cases 50%-75%
sooner. A nurse advocate, with her ongoing positive relationship with the
employer, continually works on creative back-to-work or light duty alternatives
for the injured worker. Employers are usually more amenable to partial or
light duty when they are assured by the nurse case manager that the patient
is being compliant to treatment.
- Promotes successful outcomes and limits and prevents costly litigation
down the road. The ability to sue an employer varies on a state-by-state
basis. In general, there are three reasons an injured employee tends to sue
their employer: when they feel they are not being treated fairly; when they
feel they are not being appropriately treated medically; or, when they are
not receiving their disability payments. However, if a patient feels their
employer is providing them with appropriate quality medical care until they
feel better, the case is less likely to go into litigation. Most employees
do want to get better and return to work.
Here's how the "First Call" program works. When the employee is injured,
either the employee or the employer places a call to the company's "first
call" toll-free number. The case manager, who is always a registered nurse,
obtains the demographics and details of the injury, makes a medical assessment,
and then refers the injured worker to the most appropriate network provider.
It is right at this first call that the registered nurse initiates the management
of claim and early intervention.
Working with the medical provider, the nurse case manager obtains and certifies
an acceptable treatment plan, outlining specifically the medical outcome expectations,
practice protocols, and utilization criteria. She then notifies the claims
payor of the treatment plan. All referrals to specialists hospitals, second
opinions, home health care, rehabilitation, etc. are coordinated and approved
by the "First Call" registered nurses. This case manager manages the claim
for its entire duration, making certain that the injured employee adheres
to the treatment plan, that proper medical protocols are followed, and that
medical improvement is reviewed regularly.
A well designed and monitored "First Call" management program will undoubtedly
produce cost savings to the employer. Aggressive claims management, coupled
with well designed loss control programs go hand in hand with controlling
Karen L. Andalman McIntyre is the president of Managed Care Concepts, Inc.,
based in Chicago, IL. MCC, Inc. is a leading provider of utilization review,
medical large case management, and workers' compensation claims management
programs. Karen can be reached directly at 800-732-1299 or via email at email@example.com
more articles in The HR Refresher in The CEO