Finding a Specialist for an Injured Worker

Case Management Focus

I am on a group email with about 25 workers' compensation case managers. The messages across our desks usually focus on finding a specialist in various areas to see a patient who is on workers’ compensation insurance. The specialists requested range from ENT to GI to cardiologists and many others in between.

Usually, the person requesting the specialist shares a little about the patient and that the treating physician wants to rule something out, make a diagnosis, or have the specialist treat the patient as they do not have the expertise and the condition is impacting progression of care.

Whoever has experience with the type of doctor is being asked makes a recommendation. Many times, the case manager making the request replies to a name and that the particular specialist recommended was called but will no longer take workers' compensation cases.

Hearing this is very discouraging for the group, as our resources are limited. In addition, hearing that a provider will not take a patient due to his insurance is depressing as it delays the process

I asked one of the frequent contributors why she thought so many doctors were unwilling to take workers' compensation especially the pay is better than other insurance, as the specialist is brought in as a single-case agreement.

The person said that in her encounters, she is told that specialists they do not like the rules of workers' compensation payer—there are too many forms to complete, as well as the threat of litigation. They don't want to be called to testify in a case—they just don't have time.

So, how can nurse case managers find a specialist to evaluate an injured worker who is covered under workers compensation Insurance? Here are some tips:

1. Find the specialist you want to work with and ask if they will accept workers' compensation insurance.

2. The carrier will often have a panel of physicians in their network you can utilize, so check with the adjustor to see if they have a provider network.

3. Let them know you will get a letter from the adjustor indicating the reimbursement and how soon after seeing the injured worker, they will be reimbursed.

4. Gather any paperwork the specialist needs to have regarding the injured work. Past progress note and the reason for the referral, any testing that has been done on the condition in question, specifics as to what the treating physcan wants the specialist to do – just give an opinion or does the treating physician want the specialist to diagnosis and treatment. Are they looking to know if the condition is related to the work injury or is it part of the injured workers overall health/healthcare.

5. Be organized and gather the information the specialists need to evaluate the patient. This will save time and lower the specialists' frustration with the system.

6. After the appointment, follow up to get the report and recommendations.

7. Make sure the specialists send the billing information to the insurance company in a timey manner. Then, let the adjustor know to look for it and to please pay it promptly.

8. Talk to the practice manager in the office where the specialist works. The practice manager can sometimes make an exception for the practice to see a workers compensation client.

9. Let them know you will stay involved to make sure all goes well.

Building a relationship with the specialist is important so they get a good impression of the workers compensation industry. Nurse case managers do this by improving communication and addressing barriers that come up promptly.

Have you had trouble finding specialists for your injured workers? What tips have you seen that have helped you find a specialist to evaluate the injured worker? Let me know and I can include in a future post. Email me at allewellyn48@gmail.com

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