Integrated Team-Based Medical Case Management
Reducing workers' compensation costs and lost workdays is the responsibility of everyone involved in the workers' compensation program. Although DODI 1400.25 gives the ICPA overall responsibility for the management of workers' compensation claims, including administration and return-to-work efforts, a team approach is a critical factor in the success of the overall workers' compensation program. Activities that have a good interaction among the interdisciplinary services and key players, to include the injured or ill worker, exhibit better lost time case rates and decreases in overall program costs.
Definition of Workers' Compensation Medical Case Management
Workers' compensation case management is a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an injured workers' health needs through communication and coordination of care to minimize delays in diagnosis, treatment, and return-to-work (RTW).
Expected outcomes are to retain the skills of a valued worker, reduce injury severity, prevent future injury to the employee and others, reduce lost workdays, and reduce overall compensations costs. Effective case management requires collaboration among the injury compensation program administrator (ICPA), who has overall responsibility for the installation workers' compensation program, the occupational health clinic (OHC) staff, supervisors, Personnel, the treating physician, Safety, Ergonomics, Industrial Hygiene (IH), and DOL, which has the ultimate authority for determining case disposition.
The medical contribution to case management, as defined in DoD 1400.25M, includes:
The integrated team approach to Medical Case Management (MCM) includes the above functions, but with a more proactive and organized approach, and includes:
FECA Working Groups
DOD 1400.25M provides detailed guidance on administrative management of workers’ compensation claims, as well as specific suggestions for involvement of the “medical officer” in medical reviews and evaluations to support the case management process. This personnel manual on workers’ compensation program management also describes FECA working groups for installations with greater than $1M in workers’ compensation costs. These working groups, led by the Injury Compensation Program Administrator (ICPA), have broad representation from personnel, management, safety and occupational health, and have responsibility for overseeing the management of the installation FECA program, including evaluating trends, recommending procedures and policies, and identifying problem areas. Many installations have attempted to use these FECA working groups to make case management decisions on individual problem cases, but the infrequency of meetings and the large membership hinder efficient and timely case management. In addition, focusing these high-level committees on the individual claim details distracts them from addressing the broader program issues that need attention.
Official Role of ICPA
The role of the ICPA is mandated and the responsibilities detailed in DoD 1400.25-M, SC810.3.10, et seq. The ICPA is responsible for establishing a system of administrative claim management that ensures prompt claim filing using the Electronic Data Interchange (EDI), regular reviews of open claims, collaboration with the Occupational Medicine staff for technical advice and medical case management assistance, scheduling regular case review meetings locally and with the OWCP representative, through the DoD liaison, with a frequency appropriate for the active caseload.
In addition to this established claims administration role, the role of the ICPA in an effective integrated workers’ compensation program that includes medical case management includes:
Where feasible, co-location of the ICPA with the OHC has been shown to be effective in referring the injured worker to the MCM for an initial assessment, completing the CA-1 or CA-2 in a timely manner, completing a “choice of physician” form, and returning the injured worker to the MCM for post-treatment follow-up assessments to oversee safe and progressive return to regular duties.
The Integrated MCM Team (sometimes called RTW team) is composed of the ICPA, OH physician, medical case manager (usually an OH nurse), and other command-designated personnel such as Safety/Ergonomics/IH, as needed when specific needs arise, such as when modifications in the work area are needed to facilitate safe return to work. Likewise, personnel can be brought in on an as needed basis to advise and assist in proposed actions such as separations or job offers.
This team meets frequently to discuss and make plans to facilitate safe and early RTW for employees with recent injuries, and to identify RTW opportunities for employees with long-standing partial disabilities. Individual case management planning includes development of short, intermediate, and long-term medical goals using disability guidelines, as well as determining necessary communications with the treating physician, OWCP, claimant, and supervisor.
CASES FOR REVIEW. Meetings of the team should occur frequently (weekly, biweekly or monthly, depending on caseload, with the occasional ad hoc meeting for urgent issues) to discuss specific cases, and identify next steps in case management.
Cases for team review include:
RETURN-TO-WORK TEAM ACTIVITIES. The return to work team meets to:
Medical Case Manager
ROLE OF THE MEDICAL CASE MANAGER. Although occupational health nurse experience and training is well-suited to the tasks of workers’ compensation medical case management, other clinicians (e.g. physician assistant, nurse practitioner, or physician) in the occupational health clinic could successfully take on the role of medical case manager (MCM) if needed. Additional training in the concepts of medical case management and the FECA system will be needed in some DOD installations for optimal program support in this role. The MCM should:
Provision of Medical Care
Employees are entitled to select a physician of their choice for initial assessment, provided the physician has not been barred by OWCP from conducting examinations or providing care. Employees have the option of selecting an offsite or onsite health care provider for initial assessment and follow-on treatment. Military treatment facilities can and should offer the full range of medical care for injured civilian employees. Experience at sites offering convenient and high-quality care demonstrates that many if not most employees will choose on-site care, which facilitates integrated medical case management efforts and promotes early return to work.
OWCP Medical Case Management Services
The OWCP offers a Quality Case Management Program for traumatically injured workers losing time from work. Table 1 presents the timeline for assigning a DOL field nurse to a case, the necessary coordinated agency efforts in illness and injury claims, and the many “gap” periods when there is limited or nonexistent DOL MCM. It is important to note that when there is an assigned DOL nurse, the agency must limit its involvement in RTW planning to whatever support is requested by the assigned nurse.
The following areas of need or “gaps” in medical case management are not routinely met by the OWCP program.
New Claim Medical Case Management
The RTW team should act immediately on any new injuries that require medical care beyond first aid, in order to ensure the treating physician understands medical services that can be provided on site (e.g. diagnostic procedures, physical therapy, etc.), as well as the availability of modified duty assignments. The team follows new cases closely, obtaining documentation for clinical review, and identifying RTW opportunities for those cases losing time.
For new occupational illness claims, the integrated MCM process includes review and documentation of the work hazards, provision of this data to OWCP if a claim is filed, assisting the employee in obtaining needed medical evaluation, and providing safe alternative work assignments while the claim is being adjudicated.
Aging and Old Claims
Without adequate and timely interventions, new claims can quickly become aging claims. Aging claims are those that are in adjudication or resolution limbo, and threaten to become periodic roll cases. Old claims are those that are years old and usually on the periodic rolls. Managing these cases requires collecting updated medical information from OWCP, using the DOD liaison if needed, from the claimant, or from the treating physician, with appropriate release of information consent signed by the employee. Next steps in medical case management include identification of cases that warrant second opinion exams, independent medical evaluations or functional capacity testing, and communication of these needs to OWCP. The FECA Claim File Review Form in Figure 1 can be used to facilitate review of aging and old claims. If the OWCP status is Periodic Rolls (PR) or Periodic Rolls – No Wage-Earning Capacity (PN), there are requirements that the employee must meet for submitting medical documentation, including once a year for PR and once every three years for PN cases.
FIGURE 1: FECA CLAIM FILE REVIEW
Clinical Chart Reviews
The integrated MCM approach makes liberal use of the assigned medical case manager and the occupational health physician to provide clinical reviews of charts to address the following areas:
MCM Plan Development
The RTW team develops a case management plan for each reviewed claim that includes specific case goals, team member tasks, timelines for action and timelines for completion.
POSSIBLE OUTCOMES. The possible eventual outcomes of a claim, once maximal medical improvement has been reached are:
Medical Red Flags for Fraud & Abuse
Fraud occurs when someone knowingly and with intent to mislead, presents or causes to be presented, any written statement that is materially false and in order to obtain some benefit or advantage. 18 U.S.C. § 1920 makes a knowingly false claim for these benefits a crime punishable by up to $2,000 fine or 1 year in prison or both. Fraud under FECA includes false claims for injury occurring outside the work place, claims when there is no injury at all and continuation of claims after the disability has ended. Abuse is more frequent than fraud and includes the prolongation of disability beyond the point when a claimant could RTW, through system inefficiencies and claimant sins of omission. The true cost incurred for fraudulent claims extends beyond the money paid to individuals.
A 1998 Joint OIG and Veterans Home Administration (VHA) Fraud Detection Audit indicated that potential workers’ compensation program fraud can be profiled using selected case attributes or “red flags.”