A Crushing, Complex Claim
Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.
Jerry McShane hustled as fast as he could through Chicago’s Midway Airport Concourse C on his way to his job as a baggage handler for Vista Airlines. He was late to work, for no other reason than he had spent a late night at Wrigley Field.
His beloved Cubbies had drawn out the agony, but had once again lost to the rival Milwaukee Brewers. This time the score was 4-3 in 13 innings.
As he jogged, Jerry checked to see if he had his earplugs and a backup set. You didn’t want to get caught on the tarmac without them.
Once out on the tarmac, Jerry and his buddies shouted condolences to one another over the fate of their Cubs and took turns teasing each other about their work habits. Jerry, 19, was invigorated despite the Cubbies’ loss. The hustle and flow of the airport was exciting to his young eyes and ears; people dressed up and going places.
It was a busy day on the Midway tarmac. The average passenger might not notice, but parts of Terminal C were being renovated as tractor trailers ferried new HVAC systems and other hardware for the new stores and restaurants that would serve the upgraded terminal.
Jerry was about a third of the way through his workday, slinging luggage onto the conveyor belt that bore them into the belly of a 747, bound for Miami, when he looked up and saw a girl with shimmering chestnut hair leafing through a magazine in her window seat.
Her hair was straight and fine, and was cut in an A-line bob so that it fell over her face when her head was down. When she brought her head up, she tossed her hair back and caught Jerry’s eye in that moment.
She smiled at Jerry, she was freckled and her blues eyes were sparkling. Jerry smiled back.
“Wow,” he said to himself inside.
Just then the roar of an incoming 747 rattled Jerry and he not only lost eye contact with this beautiful woman that he would never see again but momentarily lost his bearings.
He knew where the baggage cart he was unloading was. But as he broke his gaze with the girl on the plane, he turned and stepped between two parked baggage trucks, right into the path of an oncoming semi.
The steel fender of the semi slammed into Jerry, smashing his left hip and driving him under the second and third set of the truck’s wheels. Jerry screamed so loudly his co-workers heard him through their protective head gear.
The severity of Jerry’s injuries were immediately, gruesomely apparent. Jerry’s body twitched involuntarily as he entered shock. Deep, dark splotches of blood stained his jeans where his knees had been crushed.
One of Jerry’s fellow workers started ripping up his own outer shirt to make tourniquets for both of Jerry’s legs. The red-haired girl could only watch from her plane window in nauseated horror at what had just happened.
There may be insurance claims adjustors who never get out of the office to see a patient but Nancy Dunning, a workers’ compensation claims adjustor for the Evergreen Insurance Co., isn’t one of them. Nancy cares about the injured workers she encounters and something about Jerry McShane’s case had really hooked her.
The young, vibrant baggage handler had lost both of his legs below the knee due to the injuries he suffered on the Midway tarmac. His left hip injury was also severe and complicated. Jerry required additional surgery to place pins in the fractured bone. In accordance with standard procedure in these matters, Jerry had first been sent to an inpatient rehab center post-surgery where he was treated and trained to adjust to his new life.
In the weeks following Jerry’s accident, Nancy had had a myriad of issues around his case to address through phone calls and e-mails, such as lining up home healthcare, accessing durable medical equipment and his transportation and home modification needs.
In rehab, Jerry had been measured for a wheelchair that was suited to his short-term needs and an appropriate rehabilitative mattress, engineered to avoid bedsores given his severely damaged legs and broken hip. Nancy was also working with Jerry’s physiatrist, or rehab physician, on an order for prosthetic devices that would take the place of his lost lower legs.
Nancy had arranged for a nurse, that if all things went well, would only need to visit Jerry for six months or so.
Other details that were in the works included negotiations for a van that someone with Jerry’s disability could drive safely and effectively. Modifications to the family carport to fit the van were being engineered and ordered. Changes to the exterior of the McShane house were also being drawn up.
The family lived in a quasi-rural area and significant modifications to the landscaping and home entryways were going to have to be undertaken for Jerry to be able to move in and out of the house effectively on his new legs.
The prescribed drug regimen, at this point, looked pretty standard; a pain killer and an anti-anxiety medication to ease Jerry through those psychologically challenging months ahead as he adjusted to life without his lower legs.
Finally, Jerry was ready to come home and make a go of it. Nancy was in the Chicago area on business anyway, and decided to drop in and see how Jerry was doing.
She wanted to get a better idea of the interior layout of the house to see how best to implement any further durable medical equipment purchases. And besides, it never hurt to get a first-person view of things.
Nancy tried a smile when she first entered the living room of the McShane residence and Jerry smiled back from the wheelchair he sat in next to the family couch. Jerry’s mother Suzanne, who had let Nancy in the front door, was less forward.
“Hi Jerry, I’m Nancy Dunning, the person you spoke to last week.”
“Hi,” Jerry said.
There was the briefest of awkward pauses as Nancy’s eyes passed to where Jerry’s lower legs used to be.
“So how’s this chair working out?” Nancy asked quickly, to fill in the awkward gap.
“Not bad,” Jerry said.
“Doesn’t go all that fast,” he said and Nancy and Jerry laughed at Jerry’s attempt at humor.
“I don’t see what’s so funny about all of this,” Suzanne said with her arms crossed.
A red flag went up inside Nancy when she heard Suzanne’s tone. She’d dealt with these cases where family members became obstacles to good care. She hoped this wasn’t one of those families.
But after some brief back and forth, Suzanne agreed to let Nancy have a look around. What Nancy saw concerned her, and as busy as she was, it added to her doubts that she was going to have the time to give this case the attention it needed.
Jerry’s bedroom looked crammed, holding a walker, a wheelchair and some fitness equipment that had been ordered for him. Nancy didn’t like the arrangement, it looked cluttered and unsafe and could lead to further injury.
The new shower was okay, not great, but there was only so much you could do in that space. More renovations might be needed.
The kitchen really concerned Nancy. It, too, was too tight. Suzanne canned fruits and vegetables and had boxes of jars in there and it too looked cluttered and unsafe.
As she got to her car, the image of a young, game Jerry smiling and trying to make the best of things stuck with her.
“He’s a good kid, he might make a pretty good go of it,” she thought to herself.
Then her mind flashed to Suzanne, her arms crossed, standing disapprovingly to one side as she had tried to interact with Jerry.
Nancy just exhaled.
“No telling with that one, really,” she said to herself as she flipped her sunglasses down and drove away from the McShane’s.
From her desk in New Jersey, the billings in the Jerry McShane case and dozens of others were coming at Nancy Dunning like a large, dark wave.
Three times in the past calendar year Jerry McShane had been hospitalized, once for pressure sores, once for respiratory problems and a third time for an inpatient rehabilitation stay, a sort of tune up in an effort to get Jerry back on track.
His hip hadn’t healed well and it was interfering with his ability to walk with his prosthetics effectively enough to get the proper exercise.
Nancy had just opened the bill from Jerry’s latest rehab stint, a 12-day stay that had run about $280,000. Nancy looked at the bill and exhaled.
Her phone was ringing. She couldn’t pick it up, not now. On her computer monitor, e-mail messages were popping up about every five seconds, about half of them marked urgent.
To her left was a huge stack of files that needed attention. She just didn’t have time to dig into this McShane case, as expensive as it was getting.
Damn it, she’d have to make some time. Nancy looked at her phone to see if Evergreen’s nurse case manager Adrienne Moore was off the phone; she was.
“Hey Nancy,” Adrienne said as soon as she picked up the phone.
“What’s the latest on Jerry McShane, any new data?” Nancy said, drumming her fingers and looking distractedly at the pile of work she was ignoring.
“Yep, I have it but you’re not going to like it” Adrienne said.
“Go ahead,” Nancy said.
Adrienne reported that Jerry’s weight was up to 230, from 170 at the time of his injury. In addition to sores on his damaged left hip and lower back, Jerry was now suffering from open wounds on the top of his legs.
Jerry’s pharmacy intake had also ballooned. His pain killers were now joined by Correctus, an anti-depressant, Flamovin, a nerve pain treatment, Serentin, a muscle relaxant and Altidinum, a low blood pressure medication. His mother was pushing for an increase in opioid prescription frequency and volume.
“Do we know if he’s using that power lift we got him two years ago?”
“I don’t think he is using it,” Adrienne said.
“I asked his mom…wouldn’t tell me,” Adrienne said.
Nancy hung up, frustrated for the umpteenth time by Jerry’s mother.
“I do not have time for this,” Nancy said out loud as she stared out the window.
She had a quarterly report to deliver to her boss by the end of the week and it was Wednesday afternoon. No time for McShane, no time for anything.
She popped open the file that held her quarterly report. Nancy was responsible for 200 lost time files with 40 permanent disability cases in red. She looked at the McShane numbers. She couldn’t help but look at the McShane numbers.
There were $750,000 in annual costs this year alone on a case that should be just $250,000 annually. She knew the case was sinking but she just couldn’t get to all of it.
There was nothing for Nancy to do but to complete her quarterly report, which she just had to get in, and face the consequences.
Nancy Dunning is a highly competent professional who cares deeply about the injured workers whose cases she manages. But even the best intentions can become undone when busy professionals get overwhelmed by complex medical care cases with complicating family dynamics.
1. Measure once: Too often, payers and insureds are content to treat the purchase of durable medical equipment like a commodity purchase. Adjustors and claims managers who make sure that an injured worker and his/or her home are measured before equipment is purchased and delivered will get better healthcare results and lower costs in the long-term.
2. Reset if necessary: It’s a known fact that family dynamics can complicate and undermine quality of care for a permanently disabled worker. In cases where an in-home nurse or other caregiver is caught up in family dysfunction, it is sometimes necessary and advisable to remove that care giver so the family can be re-educated and given proper boundaries in the care of a permanently disable family member. Then a new care giver can be introduced to the corrected environment.
3. Do not lose touch: Managing complex medical care cases successfully means more contact, not less. Companies who are serious about getting a handle on these claims that can drive 80 to 90 percent of costs in some cases must marshall the resources to make sure that lines of communication between the patient, care givers and claims adjustors and managers are open and functional.
4. Face economic reality: Payers and insureds need to face some facts. Workers’ compensation carriers and third party administrators just don’t keep nurses on permanent disability files for the length of time that they used to. This means that case managers don’t have eyes and ears on cases to the degree that they use to and have to be much more proactive about getting good information on cases in a timely manner.
5. Don’t treat adjustors like mules: In-house adjustors can only handle so much. All companies need to watch costs, but the cost of many a complex care case is going to far exceed the human resources savings a company might achieve by cutting staff to the bone and overburdening case adjustors.