What is the Role of Case Managers in Workers Compensation?

If you’re an insurance adjuster handling workers’ compensation claims, you’ve likely encountered case managers (CMs) but may not fully understand their role. Case management is designed to coordinate medical care, reduce claim costs, and facilitate return-to-work (RTW) for injured workers (IW). Here’s how it fits into your world:

What is the Role of Case Managers?

1. Timelines & Reports

• Case Manager (CM) Assigned to a Claim: A Case Manager is typically assigned to a claim to ensure the injured worker’s (IW) recovery, treatments, and documentation/reporting requirements are up to date.
• First Report Due Within 15 Days of Referral: A timely first report helps prevent delays in care and establishes an initial action plan. During these first 15 days, the Case Manager gathers medical reports and other documentation so the adjuster can make informed decisions about treatment authorizations
• Monthly Updates & Final Closure Report: As the case progresses, the CM provides monthly updates, offering insights into treatment effectiveness and the IW’s progress.

2. Communication

• Adjusters: The CM’s first point of contact is the claims adjuster, AKA, you! Their goal is to ensure that all actions align with your claims process.
  • One big benefit of working with a CM is that you don’t have to be there during every step of the process but you still have the peace of mind that your CM will always confirm assignments with you and ensure you are informed at all times.
  • For example, if an IW needs to be referred for a second opinion or specialist consultation, the CM will notify the adjuster about the referral and update them on the outcome. This collaboration ensures that claims decisions are based on accurate and up-to-date information.
• Injured Workers’ Attorney: The CM works with the workers’ attorney to ensure that their counsel is kept in the loop and that there are no legal objections or delays.
• Medical Providers: The CM works closely with all physicians and medical providers to ensure the injured worker attends all scheduled appointments. This may involve helping the IW get transportation to appointments or following up to confirm that they have attended.
  • The Case Manager is also tasked with ensuring that the treatment plan is in line with industry standards. If the physician/provider’s suggestions don’t align with ODG guidelines then they will find a second opinion or conduct a peer review. All while documenting all findings and maintaining contact with the adjuster.
• Employer: The CM works with the employer to determine job availability and assess whether any accommodations can be made to help the IW return to work.
  • This may involve reviewing a job description or conducting a job analysis to determine if the IW can perform modified duties or if a different role is available.
  • For example, if the patient is recovering from a knee injury, the CM might work with the employer to find a temporary office-based role while they recover, allowing them to ease back into work without jeopardizing their recovery.

3. Case Management Guidelines

• 10-Year Work History: A detailed work history is essential for determining vocational options if the injured worker cannot return to their original role. If that is ever the case, the CM can identify transferable skills that might apply to other job opportunities.
• Medication Review: One of the primary tasks of the CM is to monitor medication use, especially for long-term or opioid prescriptions, as misuse can lead to prolonged disability, addiction, and increased healthcare costs.
  • For instance, if an IW is prescribed opioids after surgery, the CM may monitor for signs of overuse or recommend a shift to non-narcotic pain management if the IW’s recovery timeline suggests opioids are no longer needed.
• Length of Disability (LOD): If the IW’s recovery exceeds the expected timeline, the CM must provide an explanation, whether it’s due to complications, lack of compliance with treatment, or other barriers.
  • For example, if a worker with a back injury is unable to return to work even after the typical 12-week recovery period, the CM might investigate. Could there have been issues such as a lack of follow-up appointments, improper treatment, or an underlying condition that has extended the recovery time?
• Return-to-Work Planning: The CM plays a critical role in developing a strategy to get the IW back to work safely and as quickly as possible. This includes coordinating with medical providers and employers to provide suitable duties while the employee makes a full recovery or is physically able to work again.

Cost Savings: Vocational Rehabilitation Sample Case

In this sample case, we will not be mentioning any names or specifics in a commitment to protect the privacy of all parties involved.

In this example, a surgery scheduled for September 17, 2024, was halted early due to complications. The injured workers’ oxygen levels dropped significantly during the procedure, which made it unsafe to proceed.

The surgery was therefore canceled, and the worker was initially facing a prolonged recovery and potential need for vocational rehabilitation (VR) services, such as retraining for a different job.

Case Manager’s Role:

The case manager (CM) played a key role in facilitating the IW’s return-to-work (RTW) process despite the surgical setback.

Instead of sending the IW for vocational rehabilitation, which would have involved retraining costs for a new role (often costly), the CM worked to ensure the worker could return to their original job with modifications if needed, and without the need for further retraining.

Cost Savings:

• Vocational Retraining / VR Services: By facilitating an efficient RTW process, they avoided retraining costs—which could have been around $5,000.
• The CM helped the IW re-enter the workforce without requiring additional time off or costly services, such as job coaching, skill development, or formal retraining programs.

This case perfectly illustrates the value of proactive case management in workers’ compensation claims. Instead of defaulting to costly vocational retraining, the CM explored reasonable accommodations that would allow the IW to perform their existing job duties safely. This saved the insurance company significant costs and supported a quicker, easier recovery and reintegration into the workforce for the injured worker.

This example highlights how an experienced case manager can not only speed up recovery and reduce unnecessary expenses but also facilitate a faster, more cost-effective resolution for all parties involved.

Still unsure about what kind of CM service you need? Read more about Field Case Managers vs Telephonic Case Managers.

If you want to learn more about how Case Management might help your claims load, talk to us.