The Value of a Nurse Case Reviewer

lego nurseWorkers compensation claims can spiral out of control rather quickly with costs mounting up fast for doctor visits, test, prescriptions, and therapy.  Most times when there is a severe injury an injured worker will not see just one doctor, they may have to see several physicians who specialize in the injury type the worker has.  When an employee is first injured most times they will go see their primary care physician-sure this doctor is equipped to treat injuries and prescribe medication to subside the pain, but their focus is not on an injured worker.  The doctor has an entire practice that he needs to handle on a daily basis – and if your primary doctor is anything like mine you can sometimes feels like its a revolving door when you get in there.

Oftentimes to supplement the lack of time that your primary doctor may have to tend to you he will send for a variety of testing or imaging to diagnose the exact injury, give you some medicine to alleviate the pain or swelling and wait for the results.

Just like your primary physician may not be the best for treating your ongoing workers comp injuries – adjusters are not medical specialist by any means either.  Sure they absolutely gain a lot of knowledge by seeing claims so they know what tests, imaging, and medications are typically prescribed for certain injuries, but it certainly helps to have a medical professional looking over case loads and determining if things are appropriate to be paid, or if they are related.  A nurse reviewer will consult with contracted medical professionals on the diagnosis and the treatment course – they will then have the medical professionals reach out to the injured workers doctor on a one to one peer level basis.  This obviously does not make the doctor feel like they are being undermined.

What value does this bring to a work comp insurer?  The benefits of having a review nurse look over cases, especially complex cases, is that they can make sure that the insurer is not paying for services and procedures that are not relevant to the injury.  They can work with the primary doctor on a good course of action to get the injured worker back to work safely and quickly.  By catching services that are not relevant they can help the insurer reduce medical spend for unnecessary services.

I have spoken to insurers who send every case to a nurse review, others only do it when the case is complex or possibly spiraling out of control.  There is a lot of value that a nurse reviewer can bring to an insurer.  They bring in medical expertise that can be helpful in determining relatedness on procedures ordered by a treating physician.  What are your views on having a nurse review your case files?

What's your take? Continue the discussion with others over at the WCInsights LinkedIn Group.
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