Would Your Case Management Department Pass a DOGE Visit?  

Case Management Focus

As we watch Elon Musk and his team from the Department of Government Efficiency (DOGE) work their way through federal agencies to ensure that departments are efficient, address costs, ensure operational efficiency, and streamlined program management, I wondered how workers' compensation insurance companies, and case management departments would fare.  

To lay the groundwork 

The Department of Labor oversees federal programs through the Office of Workers’ Compensation. Each state has its own division of workers’ compensation that sets the rules for all stakeholders (employers, insurance companies who implement workers compensation programs, attorney, the regulatory bodies that are part of the system and the healthcare providers who deliver care to injured workers) to follow. 

In 2022, the National Safety Council reported the total cost of work injuries in the United States was $167 billion. This figure includes wage and productivity losses of $50.7 billion, medical expenses of $37.6 billion, and administrative expenses of $54.4 billion. This total also includes employers’ uninsured costs of $15.0 billion, including the value of time lost by workers other than those with disabling injuries who are directly or indirectly involved in injuries, and the cost of time required to investigate injuries, write up injury reports and other administrative functions. The total also includes damage to motor vehicles in work-related injuries of $5.6 billion and fire losses of $3.7 billion. 

In this article I share some thoughts and pose some questions regarding the role of case management and nurse case managers in the workers compensation system in hopes it will help you when you are called on to explain what you and your team do.  

How would You Explain to DOGE Why You and Your Team are Essentials Workrs In the Workers Compensation System?   

How would you show the value that your workers produce? What reports would you show them to justify your costs? I have written down some of the areas they are looking at and some questions that you might want to consider. I know there are other areas that are considered, but I am focusing on workers’ compensation programs and the role, function nurse case managers play in the system? Are we worth the costs to the system? Consider the following questions. 

Are we efficient?  

Nurse case managers bring educational and clinical expertise into the workers compensation area. They are viewed as valuable members of the team involved when a workplace injury occurs.  

The goal of the nurse case manager (NCM) is to assist the injured employee and facilitate the employee’s return to work through the identification of the medical services needed, the arrangement for those services to be provided, to advocate for the employee’s medical needs through communication with all medical providers, and to educate the employee on the employee’s role in the recovery process.  

Having a nurse case manager assigned to new injured workers allows for all stakeholders to be aware of the injury, its severity and the proposed plan of care. Insurance companies and case management departments should have policies and procedures in place to show when NCMs become involved in the case and the work they do to ensuring the injured worker is getting the care they need at the right time, in the least restrictive setting and in a cost-effective manner. They ensure communication is streamlined and all stakeholders are on the same page including the injured worker and the family.  

Some questions to evaluate your program to show the value of nurse case managers in the efficiency of your workers compensation program    

What policies and procedures do your nurse case managers follow as to their role as a workers compensation case manager?  

When does the nurse case manager see the injured worker after an accident occurs? Upon First report of injury? After a period of lost time?  

Is having a nurse case manager on a file helping to working to ensure workers’ compensation claims are handled efficiently and effectively? Can you provide examples? 

What strategies are in place to ensure a streamline plan is in place for an injured worker return to work? Is having a nurse case manager helpful in implementing those strategies? How successful are your nurse case managers in meeting the goals of returning an injured worker to gainful employment?  

If someone cannot go back to work/light duty work, what strategies can be put into place to address this based on the injured workers, injury and restrictions? 

What training do you provide for your nurse case managers?  

How are your nurse case managers evaluated?  

What are the costs of a claim and does having a nurse case manager involved control/lower costs?  

Nurse case managers are advanced practice nurses and bring clinical expertise to the cases they work. They understand the medical side of healthcare and can interact with the healthcare team, educate the injured worker and their family as to what is happening to them and help them have a voice in their care, so they are active members, which helps them understand the plan of care. As a result, goals are met, and outcomes are achieved. Nurse Case Managers and their managers should be able to document this to demonstrate their value with data. Some questions you might want to explore:  

• Are cases managers effective in the work they do in addressing the injured worker's needs?  

• What is the cost of each claim? How does this change if a nurse case manager is involved?  

• When did the nurse case manager see the injured worker? First report of injury? Once lost time starts to accrue?  

• Was care expedited because of their involvement?  

• Is communication streamlined?  

• Do all stakeholders know the status of claims and when the injured worker should be able to return to work? If this is not known, why and what strategies can be put into place to increase the possibilities of return to gainful employment?   

• What are your department’s return to work numbers?  

• Does your department work with employers to have return to work programs in place?  

• As part of orientation of a company you are working with are employees educated to return to work policies if they are injured. Having this type of policy ensure but the employer and the employee know that return to work programs are available and what the expectations are regarding return to work when an injury occurs.  

• If a worker cannot return to work (light duty) is it determined why?  

•  Is the injured worker engaged in the plan of care and understand the return-to-work plan? Studies show the more engaged the injured worker is, the more likely they will follow the plan of care.  

• Are issues resolved in a timely manner so that the injured worker does not feel the need to hire an attorney?  

• Are nurse case managers trained in recognizing fraud, abuse and waste?  

• What is the process to report and address this?  

• What difference did having a nurse case manager make by being involved?  Was care coordinated, were costs were controlled and the process for returning the injured worker happened in a reasonable time frame based on national guidelines. 

• Were communications streamlined?  

• Were employer, employee and provider satisfied with the process because of the nurse case managers involvement?  

Are programs streamlined to prevent workplace injuries?  

• Are injuries tracked to be aware of certain injuries happening to the workforce?  

• What strategies are put into place?  

• How are employees educated as to those strategies?  

• Do all stakeholders know what the process is when and work injury happens?   

• Are employees educated as to the process.  

• When an injury does occur does the employer (supervisors and other staff) stay in touch with the injured worker so they don’t feel abandoned?  

•  Are issues addressed when problems occur in a timely manner to the benefit of the injured worker and the employer?  

Fraud and Abuse  

• What policies are in place to identify fraud and abuse?  

• How are provider networks evaluated to make sure that they are meeting the standards they are expected to achieve for the members?  

• What is the reporting process if a nurse case managers identified providers are not meeting the standards based on their contracts?  

I hope this article helps you evaluate your case management programs. Doing this on a semiannual basis will help ensure your team is meeting the goals set or changes are made to find out why they are not meeting goals.  

If you have ideas or comments on this topic, I would love to talk to you. Please feel free to email me at allewellyn48@gmail.com  

Some reading material for leadership and their case managers:  

Triple Threat: Healthcare Fraud, Waste and Abuse in Workers' Comp: https://healthesystems.com/rxi-articles/triple-threat-healthcare-fraud-waste-and-abuse-in-workers-comp  

Removing workers’ compensation costs from the National Compensation Survey: https://www.bls.gov/opub/mlr/2023/article/removing-workers-compensation-costs-from-the-national-compensation-survey.htm 

Work Injury and Time Lost: https://injuryfacts.nsc.org/work/costs/work-injury-costs 

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