The Key Role of a Workers’ Comp Case Manager 

Close attention through the claim lifecycle ensures the best claimant outcomes  

In the world of workers’ compensation, where endless variables seem to be at play, Horizon Casualty Services, Inc., (HCS) acknowledges that having a clear sense of priorities can bring stability and consistency to claim management.  The priorities of a workers’ compensation case manager are as follows: 

• Provider referral and follow up, 

• Facilitating provider treatment plan, 

• Advocating for claimant while reducing employer exposure, 

• Serving as a resource for claimant, providing education and guidance, and 

• Serving as a liaison, reporting claimant progress to stakeholders. 

These actions dominate a case manager’s workday, but perhaps the most important action a case manager will take in the life of a claim has to be choosing the right provider. As stated by Lisa Deeves, manager of HCS case management, “if we begin with the end in mind, and focus on the claim destination, such as return to work, discharge or maximum medical improvement, then clearly the provider referral is key in accomplishing those goals.” 

According to Keleher and Stanton (2016), who interviewed 102 municipalities and large self-insured employers regarding their satisfaction with the care their workers’ compensation claimants received, they found that the selection of the provider plays a monumental role in the duration of the life of a claim.  Furthermore, they found that the case manager, as the “eyes and ears” of the employer, has a significant impact on the claim’s outcome in terms of appropriate care rendered and total dollars spent.  

This is certainly the case for HCS, where the HCS provider network offers access to professionals in the field of Orthopedics, Spine Surgery, Pain Management, Concussion Specialty, and Physical Therapy (PT), just to name a few.  Within this network, the HCS Clinical Quality team has further designated standout providers in these same specialty fields and placed them in the HCS Outcomes Focused Network (OFN).  

Determining an inclusive provider network in the HCS OFN comes with extensive research, both externally and internally.  Maura Berger, RN BSN CCM, HCS Clinical Quality Manager, explains that her team first looks externally, “we look at areas such as Board Certification, Fellowships, as well as any other field of specialization – and review the NJ Physician Discipline website for any reported issues.” Then they begin their internal review of any complaints filed with HCS.  “Afterward, we pull a random sampling from our managed claims, and we manually review for excellent claimant outcomes, administrative efficiency and minimal network leakage.”   

Lastly, they do a deep dive into claims for accurate diagnosis, strong causality, benchmarking to official disability guidelines (ODG by MCG), opioid and PT order history, return to work and duration of claim. When asked if this exhaustive review was done once, she laughed and said, “absolutely not.”  They conduct this review initially, then after inclusion in the OFN for a year they review again – and if the provider continues to meet the requirements, the review occurs on a 3-year rotation.   

Why so intense a review?  Maura explains, “only through this diligent review can we ensure that our OFN offers the highest clinical quality of care from workers’ compensation savvy providers.” 

With so many determinations in a case manager’s daily practice, choosing the right provider is clearly a sentinel choice in the life of each claim. The use of the HCS OFN providers allows case managers to confidently ensure excellent clinical care along with clear communication resulting in the best claimant outcomes.   

To learn more about HCS and its approach, contact Jed Hoban, HCS business development executive, at Jed_Hoban@HorizonBlue.com or visit https://www.horizonblue.com/horizoncasualty/service-offerings/workers-compensation. 

About HCS 

HCS, in business since 1994, is a leading PPO in New Jersey WC and PIP. HCS has a 100% direct-contracted provider network that includes almost all New Jersey acute care hospitals. The network delivers significant overall savings and, with its deep focus on precision, an extremely low appeals rate. Its PPO results, combined with its Healthcare Value Strategy and OFN, enable insurers to be the best at delivering quality medical care to claimants at the right cost — clearly a win-win for all.  

References: 

Keleher, Myrap P.; Stanton, Marietta P.  Employer Satisfaction with an Injured Employee’s Health Care, Professional Case Management, Volume 21, Number 2 March/April 2016, pp. 63-72(10) 

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