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Case Management

Missed Appointments, Missed Opportunities

Eliminating missed medical appointments can significantly reduce claims costs and improve outcomes for injured workers.
By: | September 7, 2017 • 4 min read

Non-compliance with medical protocols, including missed medical, therapeutic and diagnostic appointments, “are a problem and have always been a problem” for workers’ compensation carriers.

However, the mechanisms they and care managers use to keep tabs on injured workers produce a higher compliance rate — and better outcomes — than in the general medical environment.

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Stakeholders, including employers and insurers, “have a strong incentive to get workers back to work to reduce indemnity,” said Robert Hartwig, co-director, risk and uncertainty management center, Darla Moore School of Business, University of South Carolina.

Most employees are also eager to return to work, he said, other than a few instances of claim malingering, which preventive mechanisms tend to minimize.

Ten to 18 percent of injured workers never reach “substantial return to work,” according to new research by the Workers Compensation Research Institute that compares outcomes for injured workers in six states.

By contrast, only one percent of people on Social Security disability ever return to work, Hartwig said.

The goal of worker’s compensation — to restore to the maximum degree possible the employee’s health and ability to return to work — and the resources poured into that goal, accounts for the huge difference in outcomes, Hartwig said.

The workers’ compensation system is also sensitive to overutilization of appointments and procedures, he said.

Although no studies address the cost of missed workers’ compensation appointments specifically, all missed medical appointments cost the U.S. health care system more than $150 billion per year, said Joseph McCullough, senior vice president, transportation and language, One Call Care Management.

The cost of all non-adherence to medical protocols in the U.S. is approximately $290 billion, wrote Tomas Philipson, economist, University of Chicago, in “Forbes.” That equates to about 13 percent of total health care spending, or 2.3 percent of GDP.

Some Mechanisms

Carriers and care managers are harnessing all manner of mechanisms, high and low tech, to urge, prod and remind workers of their appointments. For example, One Call partners with Lyft to provide transportation for ambulatory workers to and from their appointments.

Through text messages limited to times, travel conditions and locations, One Call’s program seeks to prevent missed and delayed treatment caused by transportation snafus, McCullough wrote in an email interview, and instantly reschedules appointments when necessary.

Robert Hartwig, co-director, Center of Risk and Uncertainty Management at the Darla Moore School of Business, University of South Carolina

CorVel uses a three-point strategy that embraces highly coordinated care management, transportation and motivation techniques to make sure workers get to their appointments, understand their importance and accept accountability for their own recovery, said Karen Thomas, director, case management innovation, CorVel.

Its case managers — telephonic, field and one-off task managers — orchestrate scheduling with workers, issuing reminders about dates and what they need to bring. Most important, she said, “We educate them on why the appointment is important and how it impacts recovery. Case managers develop a relationship with the worker.”

Like One Call, CorVel arranges transportation for ambulatory and non-ambulatory workers. It schedules pick-ups, and through a proprietary system, communicates in real time with the worker, providers, adjuster and case manager, then documents and tracks the progress of the appointment.

Finally, Thomas said, there’s the worker’s accountability. “The worker doesn’t want to let the case manager down. After the appointment. I’ll ask, ‘Did you get what you needed? Are your questions answered?’ We don’t necessarily want to pressure the worker, but buy-in is important.”

“Our challenge is to figure out how to help workers get better despite themselves.” — Karen Thomas, director, case management innovation, CorVel

More encouragement may be necessary for the small number of injured workers who throw up roadblocks to their own recovery.

Case management is an advanced practice, Thomas said, and its nurses have experience with rehab medicine, trauma, chronic pain and its associated depression and self-sabotage.

“Our challenge is to figure out how to help workers get better despite themselves,” using every available motivation: return to an active lifestyle or playing catch with the kids.

Biggest Cost: Lost Time

Most physicians waive fees for missed appointments, said Dr. Teresa Bartlett, MD, senior vice president and medical director, Sedgwick Claims Management Services Inc. But every lost workday costs $400 to $900 as well as the worker’s lost productivity. It can also protract indemnity benefits unnecessarily.

For example, a missed appointment just prior to return to work could add a week or more to the claim if the physician can’t fit in a rescheduled appointment earlier.

Depending on the jurisdiction, deliberately missed appointments and other schemes to protract benefits can jeopardize workers’ compensation payments, Bartlett said. “That’s why we do friendly reminders. It’s in their own best interest.”

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Because timely care that conforms to best practices produces the best outcomes, Sedgwick, a claims and care manager, expedites appointments from the moment of the injury, said Bartlett. Sedgwick brings care to the worker almost immediately through telemedicine.

Sedgwick also trains its examiners to spot the signs of the behaviors and comorbidities that can lead to creeping catastrophic claims — the rolled ankle that spirals into wheelchair confinement, obesity, diabetes and heart disease, for example.

“If the worker says he just doesn’t have the energy to get into the car and go to the appointment, we’ll refer him for behavioral health intervention,” Bartlett said. “To get the case back on track, that worker will be queued up for telephonic nurse case management or field case management where a nurse goes with him to the appointment.”

Susannah Levine writes about health care, education and technology. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

The Profession

Curt Gross

This director of risk management sees cyber, IP and reputation risks as evolving threats, but more formal education may make emerging risk professionals better prepared.
By: | June 1, 2018 • 4 min read

R&I: What was your first job?

My first non-professional job was working at Burger King in high school. I learned some valuable life lessons there.

R&I: How did you come to work in risk management?

After taking some accounting classes in high school, I originally thought I wanted to be an accountant. After working on a few Widgets Inc. projects in college, I figured out that wasn’t what I really wanted to do. Risk management found me. The rest is history. Looking back, I am pleased with how things worked out.

R&I: What is the risk management community doing right?

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I think we do a nice job on post graduate education. I think the ARM and CPCU designations give credibility to the profession. Plus, formal college risk management degrees are becoming more popular these days. I know The University of Akron just launched a new risk management bachelor’s program in the fall of 2017 within the business school.

R&I: What could the risk management community be doing a better job of?

I think we could do a better job with streamlining certificates of insurance or, better yet, evaluating if they are even necessary. It just seems to me that there is a significant amount of time and expense around generating certificates. There has to be a more efficient way.

R&I: What was the best location and year for the RIMS conference and why?

Selfishly, I prefer a destination with a direct flight when possible. RIMS does a nice job of selecting various locations throughout the country. It is a big job to successfully pull off a conference of that size.

Curt Gross, Director of Risk Management, Parker Hannifin Corp.

R&I: What’s been the biggest change in the risk management and insurance industry since you’ve been in it?

Definitely the change in nontraditional property & casualty exposures such as intellectual property and reputational risk. Those exposures existed way back when but in different ways. As computer networks become more and more connected and news travels at a more rapid pace, it just amplifies these types of exposures. Sometimes we have to think like the perpetrator, which can be difficult to do.

R&I: What emerging commercial risk most concerns you?

I hate to sound cliché — it’s quite the buzz these days — but I would have to say cyber. It’s such a complex risk involving nontraditional players and motives. Definitely a challenging exposure to get your arms around. Unfortunately, I don’t think we’ll really know the true exposure until there is more claim development.

R&I: What insurance carrier do you have the highest opinion of?

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Our captive insurance company. I’ve been fortunate to work for several companies with a captive, each one with a different operating objective. I view a captive as an essential tool for a successful risk management program.

R&I: Who is your mentor and why?

I can’t point to just one. I have and continue to be lucky to work for really good managers throughout my career. Each one has taken the time and interest to develop me as a professional. I certainly haven’t arrived yet and welcome feedback to continue to try to be the best I can be every day.

R&I: What have you accomplished that you are proudest of?

I would like to think I have and continue to bring meaningful value to my company. However, I would have to say my family is my proudest accomplishment.

R&I: What is your favorite book or movie?

Favorite movie is definitely “Good Will Hunting.”

R&I: What’s the best restaurant you’ve ever eaten at?

Tough question to narrow down. If my wife ran a restaurant, it would be hers. We try to have dinner as a family as much as possible. If I had to pick one restaurant though, I would say Fire Food & Drink in Cleveland, Ohio. Chef Katz is a culinary genius.

R&I: What is the most unusual/interesting place you have ever visited?

The Grand Canyon. It is just so vast. A close second is Stonehenge.

R&I: What is the riskiest activity you ever engaged in?

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A few, actually. Up until a few years ago, I owned a sport bike (motorcycle). Of course, I wore the proper gear, took a safety course and read a motorcycle safety book. Also, I have taken a few laps in a NASCAR [race car] around Daytona International Speedway at 180 mph. Most recently, trying to ride my daughter’s skateboard.

R&I: If the world has a modern hero, who is it and why?

The Dalai Lama. A world full of compassion, tolerance and patience and free of discrimination, racism and violence, while perhaps idealistic, sounds like a wonderful place to me.

R&I: What about this work do you find the most fulfilling or rewarding?

I really enjoy the company I work for and my role, because I get the opportunity to work with various functions. For example, while mostly finance, I get to interact with legal, human resources, employee health and safety, to name a few.

R&I: What do your friends and family think you do?

I asked my son. He said, “Risk management and insurance.” (He’s had the benefit of bring-your-kid-to-work day.)

Katie Dwyer is an associate editor at Risk & Insurance®. She can be reached at [email protected]