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:
- Review all occupational illness cases; recommend action; and, if requested by ICPA, provide medical report for submission to the Office of Workers’ Compensation Programs (OWCP).
- Communicate with the treating physician to clarify medical evidence if the attempts of the ICPA fail.
- Conduct a medical review of controversial and complex cases.
- Participate in RTW process; recommend appropriate assignments.
- Assist the ICPA in communicating issues to the local medical community.
- Facilitate on-site care such as physical therapy.
- Participate in the Federal Employees’ Compensation Act (FECA) Working Group.
The integrated team approach to Medical Case Management (MCM) includes the above functions, but with a more proactive and organized approach, and includes:
- Advise the ICPA, Safety, and management of potential claims and management policies that may increase claims.
- Facilitate access to appropriate care, whether on-site or off-site, and help the ICPA network with community providers.
- Address work area hazards to prevent progression of symptoms to illnesses and injuries resulting in claims.
- Use clinic visit, claim, and lost day data to identify trends that need to be addressed through prevention.
- Use standardized disability guidelines to identify expected duration of disability.
- Participate in RTW team meetings.
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:
- Ensuring medical case managers have access to charts and data needed to support the program.
- Assembling and leading Return-to-Work Teams to include the medical case manager and/or OH physician to review cases, plan actions, and identify modified or light duty positions that are available for injured workers.
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:
- New lost time cases
- Cases in which the physician has recommended surgery
- Cases returning to work with challenging restrictions
- Prolonged temporary modified duty
- Cases with fraud/abuse red flags
- Older lost time claims, at least annually, to review medical documentation for currency and opportunities for RTW
RETURN-TO-WORK TEAM ACTIVITIES. The return to work team meets to:
- Review medical reports
- Identify cases for which controversion or other agency challenge should be considered
- Identify claim-related issues warranting safety, IH or ergonomic interventions to protect other workers or facilitate safe RTW for the claimant.
- Discuss approaches to the treating physician, OWCP, supervisor for accommodation, etc.
- Establish system for keeping track of employees on temporary light duty, and for bringing them back to the clinic for regular review of their status
- Determine actions such as requests of OWCP for 2nd opinion exam, vocational rehabilitation referral or senior level review.
- Identify appropriate personnel actions such as formal job offers or proposed terminations.
- Plan short-, intermediate-, and long-term case management goals
- Utilize standardized disability guidelines,to identify expected duration of disability for given conditions, which can be used to establish expectations with the injured worker, the treating physician and OWCP.
- Facilitate the formal job offer process by identifying the physical requirements of possible jobs to propose, and reviewing these against the employee’s permanent restrictions.
- Establish process for systematic review of medical documentation in older cases, including identifying dropped balls, such as planned independent medical evaluations that were never scheduled, etc.
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:
- Collaborate closely with the ICPA on all cases requiring medical case management attention.
- Avoid active case management activities for those cases with an assigned DOL nurse case manager.
- Identify and establish relationships with local providers, including those at the MTF as well as those in the community.
- Assist injured workers and private providers with scheduling appointments for available procedures and services.
- Assess, plan, implement, coordinate, monitor and evaluate options and services that meet an injured worker’s health and return-to-work needs.
- Use standardized duration of disability guidelines to develop expectations, goals and plans.
- Communicate with the injured worker, supervisor, ICPA, and provider(s), and other appropriate parties regarding the injured worker’s status, following the FECA rules regarding such communications, and Privacy Act provisions.
- Prepare reports, as needed, to document treatment plan, return to work plan, trends, and goal achievement.
- Perform work area evaluations in collaboration with industrial hygiene, ergonomics or safety personnel to identify presence of hazards that may be related to symptoms or that may affect RTW plans.
- Serve as a key player on multidisciplinary committees such as FECA, Safety and Occupational Health Advisory Council (SOHAC), and Ergonomics committees, as well as the RTW team.
- Work with the medical providers to identify an estimated release from care, return to modified duty or actual return-to-work date.
- Regularly review new claims, ongoing claims, and old claims to assess goal achievement within the projected time frames.
- Identify, evaluate and recommend strategies for claims where vocational rehabilitation services may produce an eventual return-to-work. Interface with vocational rehabilitation and other specialties, as appropriate.
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.
- Non-lost-time injury cases.
- During the first 15 days of a lost-time claim before a DOL telephonic nurse case manager is assigned.
- From day 15 – 120 of a lost-time claim before a case is identified for intervention and a DOL nurse is assigned to assess and monitor the claim.
- During the period after a nurse case manager has completed the assignment and the employee has not returned to work (within 120 days from filing the claim).
- After employee RTW, but in a temporary modified duty assignment.
- Whenever older PR and PN cases that are not eligible for DOL case management services but still need medical scrutiny.
- Whenever nurse case managers are not assigned to illness claims because of the length of time to adjudicate such claims (90+ days).
Table 1. Timelines for Illness and Injury Case Management
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:
- Is the disabling condition related to the accepted claimed condition?
- Is the proposed treatment course appropriate for the condition?
- Are the duty restrictions consistent with medical findings?
- Is a second opinion examination needed based on the medical review? If so, this must be requested of OWCP. In some instances, especially during the COP period, Fitness-for-Duty (FFD) procedures may be used to determine the employee’s suitability to return to light duty employment. If a second opinion is needed, a board certified specialist should be utilized.
- Is the employee is capable of working in some capacity?
- Are the absence recommendations consistent with the Official Disability Guidelines or other standardized disability guidelines?
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:
- Claimant returns to work in original position
- Claimant returns to work in a new position
- OWCP terminates compensation because (the claimant has no disability, the disability is not work-related, the claimant refuses legitimate offer of work, the claimant refuses to cooperate with vocational rehabilitation)
- Claimant is found to have permanent total disability from work-related injury and requires ongoing compensation.
- Claimant chooses retirement benefits and compensation is terminated (this outcome is frequently seen when a legitimate job offer is made to a former employee found able to work in some capacity, following years of compensation.)
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.”
- Claimant has a history of personal injury, workers’ compensation claims, and/or of reporting “subjective injuries.”
- The alleged injury relates to a preexisting injury or health problem.
- The claimant’s version of the accident has inconsistencies and is not credible.
- Accident or type of injury is unusual for the claimant’s line of work.
- Facts regarding accident are related differently in various medical reports, statements, and employer’s first report of injury.
- Claimant changes physicians for unexplained or irrational reasons.
- Claimant has concealed information regarding a previous injury, physical condition, or a medical problem.
- Stated disability is inconsistent with the requirements for total disability.
- Claimant refuses diagnostic procedures to confirm injury or refuses to attend a scheduled medical exam.
- Alleged injuries are all subjective (that is, soft-tissue pain and emotional issues).
- Claimant frequently changes physicians, or does so after being released to return to work.
- Physical description of claimant indicates muscular, well-tanned individual, with callused hands, grease under fingernails, or other signs of an active work life.
- Medical treatment is inconsistent with injuries originally alleged by employee.
- Claimant undergoes excessive treatment for soft tissue injuries.
- Treatment, as reported by claimant, is different from doctor’s statements in medical report.
- Claimant is examined by several doctors when one doctor could have taken all the information and reached a diagnosis.
- Claimant reports seeing doctor for a very brief period of time; however, reports and billing indicate a lengthy visit.
- Claimant’s description of treatment indicates non-medical personnel rendering medical treatment.
- Claimant sends in medical or reports that appear to be altered.
- Claimant lives far from medical facility, yet receives frequent treatment.
- Claimant cannot describe either diagnostic tests or treatment for which employer was billed.
- The doctor ordered diagnostic testing that is not necessary to determine extent of claimant’s injury; or, diagnostic testing is performed, yet there is no request by doctor in medical files.
- Diagnostic tests are performed by a vendor not in close proximity to doctor’s office or claimant’s home, vendor uses post office boxes on all documents, or cannot supply diagnostic records.
- Doctor or medical clinic has ownership share in diagnostic group.
- Various reports by a doctor on different claimants’ cases read identically or similarly.
- Post office box used for a clinic/doctor address instead of street address.
- Medical reports appear to be second-or-third generation photocopies.
- Physician cannot be located at address shown on documentation.
- Doctor’s report never identifies claimant by gender or gets gender wrong.
- New or additional medical problems are alleged and attributed to the original injury.
- Specific “soft-tissue” injury develops psychiatric overtones.
- Medical reports contain inaccurate terminology, spelling errors, variations in physician’s signature or are rubber-stamped with the doctor’s name.
- Medical facility uses multiple names or changes name often.
- RVS/CPT (Relative Value Scale/Current Procedural Terminology) codes show evidence of upgrading level of or splitting services.
- Billings are received for unnecessary or not rendered services
- Medical facility has consistently billed both OWCP and private insurance carrier and has received payments from both.
- Claimant is unable to define medical ailments as listed on claim form.
- Lawyer’s letter of representation or letter from medical clinic is first notice of claim.