Case Management Referral

It is important that the employee receive quality care, and this is where Cost Containment Solutions medical management can play an important role in the outcome of the claim.  It is critical that there be open communication between the employee, the employer, and the medical provider.  This begins the flow of communication to the claims adjuster.  Information sharing between professionals benefits everyone involved in the claim.  A medical provider should be familiar with the company and understand their policies and procedures, especially with their return to work programs.  It is important to have providers who understand workers compensation issues.  Having this relationship with the provider and the employer helps everyone provide the best possible outcome for all.

Every company has guidelines as to when and or under what circumstances a claim is referred to medical management.  There are clinical indicators for special services for case management.

Indicators recommending case management

1. Lapse greater than two weeks between the accident date and the first date of treatment.
2. Gaps in treatment, treatment more than 3 times per weeks.
3. Treatment longer that 3 months in duration. 
4. Medical or therapy provider visits greater than 15 non-managed care settings. 
5. Pre-existing medical problems TMJ, dental, chronic diseases or multiple medical issues.
6. Diagnostic procedures that appear excessive.
7. Unusual multiple medical providers or “doctor shopping”.
8. Poor attendance for medical or therapy appointments.
9. Accident history that is minor compared to complaints.
10. Care that  seems to be unrelated to the accident or illness.
11. Symptom magnification, exaggeration or bizarre complaints.
12. Inpatient hospitalization greater than 5 days. 
13. Catastrophic injuries such as brain/head injuries, spinal cord injuries, or major burns.
14. Long term psychological treatment for minor injuries. 
15. Intensive use of addictive medications. 
16. Injuries causing prolonged disability exceeding 5 weeks. 
17. Wage loss greater than 7 days.
18. Essential services greater than 2 weeks. 
19. Billing for durable medical equipment which exceeds $250. 
20. Provider’s bill is greater than is “usual and customary” for the location, or shows indication of unbundling or creative billing. 
21. Charges seem redundant, duplicated or unrelated. 
22. Chiropractic visits greater than 12. 
23. Inpatient hospitalization exceeds 2 utilization management concurrent reviews.
24. Post-discharge need for home care or physical therapy services.
25. Poor employment history or limited vocational options exist.