PLL Associates Approach & Best Practices
- Prompt effective 48-hour 3-point voice to voice contact with the injured worker, employer and physician, on all assignments.
- File assigned to the appropriate Nurse Case Manager based upon case complexity and potential financial exposure.
- Appropriate file supervision.
- Timely recognition of medical exposure.
- Appropriate, clear and concise file documentation.
- Compliance with any Special Handling Agreements.
- Data quality and reliability.
- Compliance with jurisdictional statutes, rules and regulations.
- Compensable lost-time claims where medical intervention will positively impact the return-to-work outcome.
- Claims with excessive, inappropriate or uncoordinated medical care.
Introduction And Philosophy
Developing an Early Intervention Strategy begins with initial and subsequent contacts. An early intervention strategy sets the tone for case development and drives our management of medical care, Return to Work and claim resolution strategies.
The goal for the Nurse Case Manager is to achieve prompt, effective voice-to-voice contact with the injured worker, employer and physician within 48 hours from the date of the medical referral on all lost time claims.
Commitment
As part of our commitment to extraordinary customer service, we have committed to the following standard for initial contacts:
Speaking directly with all parties involved quickly facilitates our ability to gather and rapidly acts upon pertinent information to assist the claims adjusters to make a compensability decision and identify any offset potential.
Contact letters, messages and other indirect communication are used only as last resorts after multiple documented attempts are made for direct communication.
All required voice-to-voice contacts are to be completed within the initial 48-hour period from the referral date.
Quality <span style="color:#CBA052"Contact
Quality contact is as important as timely contact. Only when the proper information is obtained can we evaluate the claim, determine what claims and/or medical resources are necessary, and initiate the most appropriate claim management strategies necessary to resolve the case. When initial contact with the employer, employee or treating physician is made, the information listed on the following chart should be obtained as appropriate.
Nurse Case Manager Contacts will be made within 48 hours of the referral and will contain the following information:
Employer:
- Inform employer that a medical case manager has been assigned to assist the injured worker in all return-to-work efforts.
- Discuss the availability of a modified duty program.
- Obtain a detailed job description from the direct supervisor and willingness to accommodate any potential work restrictions.
- Provide the employer with the injured worker’s estimated return to work date, if known.
- Determine if there are any union restrictions preventing an early return to work.
Injured Worker:
- Establish a rapport with the injured worker as an assistant in the return work process.
- Obtain specific information regarding injured worker’s understanding and compliance with treatment plan, description of injury, future course of medical treatment.
- Establish an expectation for safe and timely return to work.
- Answer medical questions or concerns related to the treatment of injury.
- Obtain background information such as past employment skills, educational background, and any social factors affecting a return to work.
- Ascertain whether the injured worker is satisfied with their current medical provider.
- If appropriate, channel the injured worker to a network provider or specialist.
Medical Provider:
Obtain specific medical information to include:
- Treatment plan.
- Specific diagnosis and prognosis.
- Estimated return to work date.
- Objective/subjective findings.
- Next office visit.
- Inform provider if the employer has a modified duty program, or is willing to accommodate restrictions.
- Discuss process for requesting authorizations of medical treatment.
- Request hard copy of medical records.
Quality <span style="color:#CBA052"Contact
Quality contact is as important as timely contact. Only when the proper information is obtained can we evaluate the claim, determine what claims and/or medical resources are necessary, and initiate the most appropriate claim management strategies necessary to resolve the case. When initial contact with the employer, employee or treating physician is made, the information listed on the following chart should be obtained as appropriate.
Nurse Case Manager Contacts will be made within 48 hours of the referral and will contain the following information:
Employer:
- Inform employer that a medical case manager has been assigned to assist the injured worker in all return-to-work efforts.
- Discuss the availability of a modified duty program.
- Obtain a detailed job description from the direct supervisor and willingness to accommodate any potential work restrictions.
- Provide the employer with the injured worker’s estimated return to work date, if known.
- Determine if there are any union restrictions preventing an early return to work.
Injured Worker:
- Establish a rapport with the injured worker as an assistant in the return work process.
- Obtain specific information regarding injured worker’s understanding and compliance with treatment plan, description of injury, future course of medical treatment.
- Establish an expectation for safe and timely return to work.
- Answer medical questions or concerns related to the treatment of injury.
- Obtain background information such as past employment skills, educational background, and any social factors affecting a return to work.
- Ascertain whether the injured worker is satisfied with their current medical provider.
- If appropriate, channel the injured worker to a network provider or specialist.
Medical Provider:
Obtain specific medical information to include:
- Treatment plan.
- Specific diagnosis and prognosis.
- Estimated return to work date.
- Objective/subjective findings.
- Next office visit.
- Inform provider if the employer has a modified duty program, or is willing to accommodate restrictions.
- Discuss process for requesting authorizations of medical treatment.
- Request hard copy of medical records.
During <span style="color:#CBA052"ALL Periods of Disability
The nurse case manager will encourage a timely, appropriate return to work. Continued contact with the injured worker, employer and physician must be made at intervals consistent with the injury. We must:
- Promote a team approach to limiting the extent of disability.
- Develop a return-to-work plan that includes the establishment of a return-to-work target and promptly adjust the plan as facts change.
- Provide the treating physician with a complete job description to facilitate an objective evaluation of the injured worker’s ability to return to work.
- Provide technical assistance to the employer in the development of a transitional and/or modified job, when necessary.