We work closely with our clients to help them develop a sound postinjury management process. We provide resources for the documentation and investigation of a claim, and offer convenient options for filing a new injury report. When employers respond quickly and effectively to a workplace injury, it enhances employee confidence and cooperation with policies and best practices. Ultimately, our goal is to reduce the time away from work due to an injury. Preparation, organization and early medical intervention are key assets in accomplishing this goal.

Engaging our nurse case managers early in the process promotes improved clinical outcomes, supports return-to-work efforts and helps reduce our client’s loss costs. The case manager’s role includes:

• Working with the claims examiner to develop and implement a plan to help the employee recover and return to work
• Performing initial and ongoing clinical assessments of the employee and evaluating the need for alternative treatment
• Negotiating and coordinating appropriate medical treatment and length of disability based on current, evidence-based guidelines
• Facilitating communication between all involved parties

Early intervention includes three important objectives:

• Immediately providing assistance to the injured employee
• Quickly organizing injury and claim information to facilitate better communication with all parties
• Engaging professional and clinical resources early in the claim to help prevent delays

We evaluate our performance through our internal quality program and our external URAC accreditation for case management. The goals of case management in workers’ compensation are to:

• Contain medical costs and negotiate cost savings when possible
• Prevent unnecessary time off work
• Identify and remove barriers to recovery

The transitional work services program is a strategic, customized return-to-work option for employers. It involves on-site physical therapy to link the recovery process to the work site and job demands to help the employee return to full duty faster. Programs like this can help employers maintain control over claims by directing their employees to great occupational healthcare.

Vocational rehabilitation is an option for an injured employee when other return-to-work efforts are exhausted, or when the injuries are so severe that they will not be able to return to their original position. The program involves a qualified rehabilitation professional meeting personally with the employee to develop a specific plan to accomplish a work-related goal, such as return to the same job, return to a different job, same/different employer, etc.

Job retention services can be used when an employee is having difficulty progressing to their former position after returning to work on transitional duty. Claims must be lost time (eight or more calendar days) to be eligible. These services can be incorporated whether or not an employer has used transitional work services. As a part of the program, a qualified rehabilitation professional will be personally involved in field case management with the employee and their physician. Various services are provided through this program including job analyses, job modification, on-the-job training, physical therapy, occupational therapy, tools, supplies, etc. The benefits include cost containment for the employer and quicker return-to-work outcomes for the employee.

Remain-at-work services can be used when an employee is having difficulty progressing to their former position after returning to work on transitional duty. It is for medical-only claims where employees return to work in seven calendar days or less. This option can be incorporated whether or not employers have used transitional work services. As a part of the program, a qualified rehabilitation professional will be personally involved in field case management with the employee and the physician. Services include job analyses, job modification, on-the-job training, physical and occupational therapy, supplies, etc. The managed care organization, employee and employer (with the cooperation of the physician of record) must approve the program.

When an injured employee is released to modified duty by a physician, but the employer has no opportunities to accommodate the request, alternative solutions are needed to help them return to work. Our modified duty off-site program can help by providing injured employees with temporary work at a not-for-profit organization in their community. The employee is able to contribute to society in a meaningful way, working within their restrictions as they recover. The program helps employers reduce overall lost time, medical costs and recovery time. Our vocational experts identify placement opportunities and oversee the transitional duty process. Our disability management team follows the employee’s treatment and recovery progress to help them safely return to full duty.

Prescription oversight is essential for effective medical management. Medication side effects can often delay a return to work, or even endanger employees once they are back at work. Through aggressive review of prescription drugs, we protect injured employees from potentially harmful combinations that could interfere with treatment and work expectations. We routinely identify instances where a questionable medication is prescribed.

Our drug utilization review team is focused on:

• Ensuring medications are appropriate for the allowed conditions and active treatment
• Eliminating unrelated and excessive prescriptions and monitoring opioid use
• Identifying alternative, non-narcotic medications that produce fewer side effects and permit earlier return to work
• Submitting sound and well-researched drug utilization review requests — each one is reviewed by our physician panel to ensure we facilitate the best possible outcome

To help employers control medical costs, we follow the fee schedule from the Ohio Bureau of Workers’ Compensation and then provide additional savings through PPO network reductions, clinical edits on specific billed procedures and direct negotiations with providers on duration of treatment. Our medical treatment management system is tied directly to our billing system, ensuring that any bills submitted for medical treatment that are not pre-approved for the claim are not paid.