Nurse Case Management

On the Case

Payers are looking for spirited nurse case managers who will be patient motivators and advocates, not slaves to process.
By: | October 15, 2014 • 7 min read

Chances are greater today than ever that a workers’ compensation claimant will speak with a registered nurse, either telephonically or in person.

There is also greater likelihood that an injured worker with an ongoing claim will interact with a nurse case manager earlier in the life of that claim than occurred in the past. Those with new injuries, meanwhile, are more likely to speak with a “triage” nurse to help determine whether they need further medical assistance.


Increasingly, nurses are being used in a variety of workers’ comp roles, from providing counseling for injured workers, to becoming more aggressive questioners and overseers of medical treatment.

Hence, the constant appearance of want ads placed by workers’ comp companies seeking registered nurses, usually with case management skills, capable of helping manage disabilities and returning injured workers to the job.

Expect to see the number of those want ads grow as workers’ comp payers look to stem increasing claims complexity and medical expenses.

Over the next several years, employment of U.S. nurse case managers is expected to grow 3.3 percent annually. At the same time, the medical case management industry’s revenue is expected to grow by 3.6 percent annually, to an estimated $6.7 billion in 2018, according to a September 2013 report by IBIS World, an industry intelligence and research firm.

Those statistics reflect an expected growth in demand for all nurse case managers, including those working in group health. But much of the growth will come from workers’ comp, as the number of workers in the U.S. increases, the report stated.

Historically, hiring trends for nurses in group health and workers’ comp are cyclical.

Efforts to hire workers’ comp nurse case managers plateaued about five to seven years ago following a “huge increase,” said Linda Walker, a board member of the American Association of Occupational Health Nurses.

The growth spurt came when workers’ comp insurers and third-party administrators found they needed more registered nurses to help comply with increasingly complex medical laws and to ensure medical providers followed treatment guidelines, she said.

The hiring run ended due to the Great Recession’s impact on employment, according to IBIS World.

Part of the reason case nurses are so much more in demand today is that claims are much more complex today than in years past, said Liz Thompson, CEO at Encore Unlimited LLC, a case management company in Stevens Point, Wisc.

Comorbidities, an aging workforce, and narcotic prescriptions are driving claims complexities. Nurses are also spending more time addressing behavioral and psychosocial issues beyond the original workplace injury, Thompson said.

“Nurse case managers are really needed to help the insurance community navigate through these complex issues,” Thompson said.

Burgeoning Job Rolls

The proof of that need is that workers’ comp insurers and third-party administrators interviewed for this story said they employ many more nurses today than they did a decade ago.

Sedgwick Claims Management Services Inc., for example, employs more than 400 nurses, double the amount of five years ago, said Teresa Bartlett, senior VP and medical director at the company.

Travelers employs more than 500 registered nurses servicing workers’ comp claims nationwide. Their use was made necessary as the ratio of medical expense to indemnity costs for an average claim increased, said Jim Wucherpfenning, VP of workers’ compensation for Travelers.


Assigning nurses with the knowledge and communication skills to interact with injured workers and doctors alike speeds the recovery process and gets workers back on the job sooner, he said.

“We believe you get the best medical case management when those pieces of a claim are handled by a medical professional,” Wucherpfenning said.

Other claims payers have also increased in-house nursing staff to manage medical care costs.

“The operational models of carriers or payers increasingly have some commitment to in-house nursing to supplement adjusting staff,” said Ronald J. Skrocki, VP, product management and development at GENEX Services Inc. “Maybe 15 years ago there was some of that.”

Skrocki said it is hard to find a major payer today that isn’t using more nurses either in-house or in an outsourced function. No matter how the industry accesses the talent, it needs more of it, he said.

Melinda Hayes, president and CEO of managed-care company MHayes, said that while some large workers’ comp insurers employ hundreds of nurses, they also contract with her company for nurse field case managers and to bolster their telephonic nursing staff.

For older, complex claims, she has seen her nurse field case managers called in earlier today, with the average time from injury to referral dropping from 2.53 years in 2011 to 1.84 years in 2014, Hayes said.

Predictive analytics also plays a role, as it helps adjusters determine which cases will benefit from nurse oversight of medical care. The technology also helps ensure nurses are not unnecessarily assigned to cases that won’t benefit from their involvement, preventing wasteful expenses, experts said.

Slaves to Process

Insurers and other companies providing case managers and other nursing services also have best practices, treatment guidelines, protocols and client handling instructions that their nurses must follow. The measures are intended to help deliver proper care to speed recovery.

But some workers’ comp observers express concern that today’s case managers spend their workday adhering to those processes, rather than critically evaluating claims and applying their medical expertise to improve outcomes.

“I don’t need to pay for you to scribe. I need a critical thinker and a decision-maker and to challenge what is happening in the exam room.” — Judie Tsanopoulos, director of workers’ comp and loss control, St. Joseph Health System

Field case management nurses are now far less likely to engage in critical practices such as questioning a doctor’s treatment decisions when necessary, said Sherri Hickey, director of medical management for workers’ compensation insurer Safety National.

Instead they focus on following protocols and processes, such as making sure patients find their way to a contracted medical provider network. She doesn’t see as many nurses with the “more aggressive, challenging attitude” she believes is necessary.


“I find some of the nurses now are a lot more process-oriented,” she said.

“They get a little busy with all that work and they are not really focusing on what is the best outcome for the patient. It is more processing than it is looking at the best outcome and how to facilitate that best outcome.”

Hickey is a registered nurse supervising two other Safety National nurses. Hickey and the Safety National in-house nurses in turn police the field case managers assigned to claims by TPAs to make sure the field case managers are doing their jobs properly.

“We are calling those case managers and having discussions on the phone and saying, ‘Have you asked the [medical provider]this question, have you pursued this theory, have you asked them why they are doing this versus that,’ ” she said.

Sherri Hickey, director of medical management, Safety National

Sherri Hickey, director of medical management, Safety National

“We force them into that a little more.”

Judie Tsanopoulos, director of workers’ comp and loss control at St. Joseph Health System in Orange, Calif., agreed that some field case managers have become increasingly process-oriented to the detriment of good patient care.

“Absolutely,” she said. “We have had difficulty finding good nurse case managers.”

She discontinued relations with some field case management companies because their nurses merely accompanied claimants to medical appointments and took notes, but did not ask enough probing questions.

“I would get their reports and all they did was scribe,” Tsanopoulos said.

“I don’t need to pay for you to scribe. I need a critical thinker and a decision-maker and to challenge what is happening in the exam room,” she said.

“That is what I want to pay for and I want them to take their technical skills and clinical skills and utilize them.”

Done right though, nurse case management can have a huge impact on resolving claims.

Tsanopoulos said she spends significant sums for the liberal use of nurse case managers. It increases spending up-front but ultimately reduces claims durations and the costs of ongoing claims.

Motivational Interviewing

Over the years, the roles and training of workers’ comp nurse case managers has evolved, experts said.

Today’s nurses, for example, are more likely to be trained in “motivational interviewing,” said Susan DeMarino, vice president of accreditation services at URAC, a Washington, D.C.-based nonprofit that accredits case management and other health care programs.

The training includes best practices for eliciting information from claimants and empathizing with patients who may be mistrustful of the workers’ comp system.


“Case managers are getting additional training and education on how to ask questions to better engage the injured worker,” she said. “We started hearing about it about five years ago, but we are starting to see it being applied more.”

Of course, how well nurse case managers perform will be up to the individual. Rest assured, the workers’ compensation risk management industry needs as many of the good ones as it can get these days.


Read more of our three-part series on nurse case management:

10152014_04_indepth_series_nurse_150x150Part IOn the Case

Payers are looking for spirited nurse case managers who will be patient motivators and advocates, not slaves to process.

11012014_09_indepth_150x150Part IIHow Much Is Too Much?

Nurse case managers can provide vital consultation, but contractual limits to the expenses associated with the service are advisable.

Part III: Available in the December 2014 issue.


Roberto Ceniceros is senior editor at Risk & Insurance® and chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at [email protected] Read more of his columns and features.

More from Risk & Insurance

More from Risk & Insurance

Exclusive | Hank Greenberg on China Trade, Starr’s Rapid Growth and 100th, Spitzer, Schneiderman and More

In a robust and frank conversation, the insurance legend provides unique insights into global trade, his past battles and what the future holds for the industry and his company.
By: | October 12, 2018 • 12 min read

In 1960, Maurice “Hank” Greenberg was hired as a vice president of C.V. Starr & Co. At age 35, he had already accomplished a great deal.

He served his country as part of the Allied Forces that stormed the beaches at Normandy and liberated the Nazi death camps. He fought again during the Korean War, earning a Bronze Star. He held a law degree from New York Law School.


Now he was ready to make his mark on the business world.

Even C.V. Starr himself — who hired Mr. Greenberg and later hand-picked him as the successor to the company he founded in Shanghai in 1919 — could not have imagined what a mark it would be.

Mr. Greenberg began to build AIG as a Starr subsidiary, then in 1969, he took it public. The company would, at its peak, achieve a market cap of some $180 billion and cement its place as the largest insurance and financial services company in history.

This month, Mr. Greenberg travels to China to celebrate the 100th anniversary of C.V. Starr & Co. That visit occurs at a prickly time in U.S.-Sino relations, as the Trump administration levies tariffs on hundreds of billions of dollars in Chinese goods and China retaliates.

In September, Risk & Insurance® sat down with Mr. Greenberg in his Park Avenue office to hear his thoughts on the centennial of C.V. Starr, the dynamics of U.S. trade relationships with China and the future of the U.S. insurance industry as it faces the challenges of technology development and talent recruitment and retention, among many others. What follows is an edited transcript of that discussion.

R&I: One hundred years is quite an impressive milestone for any company. Celebrating the anniversary in China signifies the importance and longevity of that relationship. Can you tell us more about C.V. Starr’s history with China?

Hank Greenberg: We have a long history in China. I first went there in 1975. There was little there, but I had business throughout Asia, and I stopped there all the time. I’d stop there a couple of times a year and build relationships.

When I first started visiting China, there was only one state-owned insurance company there, PICC (the People’s Insurance Company of China); it was tiny at the time. We helped them to grow.

I also received the first foreign life insurance license in China, for AIA (The American International Assurance Co.). To date, there has been no other foreign life insurance company in China. It took me 20 years of hard work to get that license.

We also introduced an agency system in China. They had none. Their life company employees would get a salary whether they sold something or not. With the agency system of course you get paid a commission if you sell something. Once that agency system was installed, it went on to create more than a million jobs.

R&I: So Starr’s success has meant success for the Chinese insurance industry as well.

Hank Greenberg: That’s partly why we’re going to be celebrating that anniversary there next month. That celebration will occur alongside that of IBLAC (International Business Leaders’ Advisory Council), an international business advisory group that was put together when Zhu Rongji was the mayor of Shanghai [Zhu is since retired from public life]. He asked me to start that to attract foreign companies to invest in Shanghai.

“It turns out that it is harder [for China] to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

Shanghai and China in general were just coming out of the doldrums then; there was a lack of foreign investment. Zhu asked me to chair IBLAC and to help get it started, which I did. I served as chairman of that group for a couple of terms. I am still a part of that board, and it will be celebrating its 30th anniversary along with our 100th anniversary.


We have a good relationship with China, and we’re candid as you can tell from the op-ed I published in the Wall Street Journal. I’m told that my op-ed was received quite well in China, by both Chinese companies and foreign companies doing business there.

On August 29, Mr. Greenberg published an opinion piece in the WSJ reminding Chinese leaders of the productive history of U.S.-Sino relations and suggesting that Chinese leaders take pragmatic steps to ease trade tensions with the U.S.

R&I: What’s your outlook on current trade relations between the U.S. and China?

Hank Greenberg: As to the current environment, when you are in negotiations, every leader negotiates differently.

President Trump is negotiating based on his well-known approach. What’s different now is that President Xi (Jinping, General Secretary of the Communist Party of China) made himself the emperor. All the past presidents in China before the revolution had two terms. He’s there for life, which makes things much more difficult.

R&I: Sure does. You’ve got a one- or two-term president talking to somebody who can wait it out. It’s definitely unique.

Hank Greenberg: So, clearly a lot of change is going on in China. Some of it is good. But as I said in the op-ed, China needs to be treated like the second largest economy in the world, which it is. And it will be the number one economy in the world in not too many years. That means that you can’t use the same terms of trade that you did 25 or 30 years ago.

They want to have access to our market and other markets. Fine, but you have to have reciprocity, and they have not been very good at that.

R&I: What stands in the way of that happening?

Hank Greenberg: I think there are several substantial challenges. One, their structure makes it very difficult. They have a senior official, a regulator, who runs a division within the government for insurance. He keeps that job as long as he does what leadership wants him to do. He may not be sure what they want him to do.

For example, the president made a speech many months ago saying they are going to open up banking, insurance and a couple of additional sectors to foreign investment; nothing happened.

The reason was that the head of that division got changed. A new administrator came in who was not sure what the president wanted so he did nothing. Time went on and the international community said, “Wait a minute, you promised that you were going to do that and you didn’t do that.”

So the structure is such that it is very difficult. China can’t react as fast as it should. That will change, but it is going to take time.

R&I: That’s interesting, because during the financial crisis in 2008 there was talk that China, given their more centralized authority, could react more quickly, not less quickly.

Hank Greenberg: It turns out that it is harder to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.

R&I: Obviously, you have a very unique perspective and experience in China. For American companies coming to China, what are some of the current challenges?


Hank Greenberg: Well, they very much want to do business in China. That’s due to the sheer size of the country, at 1.4 billion people. It’s a very big market and not just for insurance companies. It’s a whole range of companies that would like to have access to China as easily as Chinese companies have access to the United States. As I said previously, that has to be resolved.

It’s not going to be easy, because China has a history of not being treated well by other countries. The U.S. has been pretty good in that way. We haven’t taken advantage of China.

R&I: Your op-ed was very enlightening on that topic.

Hank Greenberg: President Xi wants to rebuild the “middle kingdom,” to what China was, a great country. Part of that was his takeover of the South China Sea rock islands during the Obama Administration; we did nothing. It’s a little late now to try and do something. They promised they would never militarize those islands. Then they did. That’s a real problem in Southern Asia. The other countries in that region are not happy about that.

R&I: One thing that has differentiated your company is that it is not a public company, and it is not a mutual company. We think you’re the only large insurance company with that structure at that scale. What advantages does that give you?

Hank Greenberg: Two things. First of all, we’re more than an insurance company. We have the traditional investment unit with the insurance company. Then we have a separate investment unit that we started, which is very successful. So we have a source of income that is diverse. We don’t have to underwrite business that is going to lose a lot of money. Not knowingly anyway.

R&I: And that’s because you are a private company?

Hank Greenberg: Yes. We attract a different type of person in a private company.

R&I: Do you think that enables you to react more quickly?

Hank Greenberg: Absolutely. When we left AIG there were three of us. Myself, Howie Smith and Ed Matthews. Howie used to run the internal financials and Ed Matthews was the investment guy coming out of Morgan Stanley when I was putting AIG together. We started with three people and now we have 3,500 and growing.

“I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

R&I:  You being forced to leave AIG in 2005 really was an injustice, by the way. AIG wouldn’t have been in the position it was in 2008 if you had still been there.


Hank Greenberg: Absolutely not. We had all the right things in place. We met with the financial services division once a day every day to make sure they stuck to what they were supposed to do. Even Hank Paulson, the Secretary of Treasury, sat on the stand during my trial and said that if I’d been at the company, it would not have imploded the way it did.

R&I: And that fateful decision the AIG board made really affected the course of the country.

Hank Greenberg: So many people lost all of their net worth. The new management was taking on billions of dollars’ worth of risk with no collateral. They had decimated the internal risk management controls. And the government takeover of the company when the financial crisis blew up was grossly unfair.

From the time it went public, AIG’s value had increased from $300 million to $180 billion. Thanks to Eliot Spitzer, it’s now worth a fraction of that. His was a gross misuse of the Martin Act. It gives the Attorney General the power to investigate without probable cause and bring fraud charges without having to prove intent. Only in New York does the law grant the AG that much power.

R&I: It’s especially frustrating when you consider the quality of his own character, and the scandal he was involved in.

In early 2008, Spitzer was caught on a federal wiretap arranging a meeting with a prostitute at a Washington Hotel and resigned shortly thereafter.

Hank Greenberg: Yes. And it’s been successive. Look at Eric Schneiderman. He resigned earlier this year when it came out that he had abused several women. And this was after he came out so strongly against other men accused of the same thing. To me it demonstrates hypocrisy and abuse of power.

Schneiderman followed in Spitzer’s footsteps in leveraging the Martin Act against numerous corporations to generate multi-billion dollar settlements.

R&I: Starr, however, continues to thrive. You said you’re at 3,500 people and still growing. As you continue to expand, how do you deal with the challenge of attracting talent?

Hank Greenberg: We did something last week.

On September 16th, St. John’s University announced the largest gift in its 148-year history. The Starr Foundation donated $15 million to the school, establishing the Maurice R. Greenberg Leadership Initiative at St. John’s School of Risk Management, Insurance and Actuarial Science.

Hank Greenberg: We have recruited from St. John’s for many, many years. These are young people who want to be in the insurance industry. They don’t get into it by accident. They study to become proficient in this and we have recruited some very qualified individuals from that school. But we also recruit from many other universities. On the investment side, outside of the insurance industry, we also recruit from Wall Street.

R&I: We’re very interested in how you and other leaders in this industry view technology and how they’re going to use it.

Hank Greenberg: I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.

R&I: So as the pre-eminent leader of the insurance industry, what do you see in terms of where insurance is now and where it’s going?

Hank Greenberg: The country and the world will always need insurance. That doesn’t mean that what we have today is what we’re going to have 25 years from now.

How quickly the change comes and how far it will go will depend on individual companies and individual countries. Some will be more brave than others. But change will take place, there is no doubt about it.


More will go on in space, there is no question about that. We’re involved in it right now as an insurance company, and it will get broader.

One of the things you have to worry about is it’s now a nuclear world. It’s a more dangerous world. And again, we have to find some way to deal with that.

So, change is inevitable. You need people who can deal with change.

R&I:  Is there anything else, Mr. Greenberg, you want to comment on?

Hank Greenberg: I think I’ve covered it. &

The R&I Editorial Team can be reached at [email protected]