At the beginning of a claim, it can be difficult to know if or when referring to a case manager would be helpful. Having a case manager at the beginning of every claim would seem valuable, but it would dramatically increase overall costs, stretch limited resources too thin, and might fail to focus on critical claims.
Benefits of Case Management
Historically, knowing if and when to use these limited resources has been elusive. However, new tools, like Claim Clarity, are now available to help identify which claims would benefit from referral, along with providing risk assessment and long-term disability predictor scores. Artificial intelligence powers these decisions based on learnings from millions of historic cases that were completed.
Several models support the benefits of case management, with studies going back decades. A 1987 Intracorp study reviewed 300,000 disability claims and identified timely referral to a case manager as the best predictor of a good outcome. More recently, a 2015 report from Safety National compared shoulder surgery claims with a nurse case manager at one employer, to claims without a case manager at 31other companies. The study found 57% shorter disability durations for the managed cases, 18% reduction in projected medical costs, 26% reduction in total loss dollars, and 15% reduction in additional lost time from work.
Yet some critics contend that case managers are not advocates for the claimant, but simply an extension of the claim adjuster, only representing the interests of the insurance carrier. While there are a few bad actors in all professions, most case managers take their role of patient advocate seriously. While they may be paid directly or indirectly by an insurance carrier, they ultimately help claimants return to their functional baseline by providing education, guidance, and support.
Instant Referrals to Eliminate Delays
Timing of the referral is critical for achieving the greatest impact. Often referrals are made reactively in scenarios such as these:
- Reported impairments are inconsistent with the documentation
- Treating medical providers have been unresponsive or fail to offer a clear rationale to support ongoing impairments
- A case has a complex clinical presentation with no clear course to resolution
For example, consider a person with both a shoulder sprain and a fibromyalgia claim. Using one of the many industry risk assessment scoring tools, the adjuster could identify the fibromyalgia claim as high risk and refer for case management earlier, while managing the shoulder sprain claim themselves, resulting in better outcomes for both.
Such scenarios, and many others, may indeed benefit from a referral, but delays in identifying a complication create problems. A good outcome is more difficult to achieve with a delayed referral. However, most disability programs now have tools available, many integrated in the claim system or through dynamic linking, that can streamline this process allowing for referrals to be made proactively, before going “off the tracks.” This can significantly reduce and/or eliminate the impact of barriers, reducing or eliminating delays.
Automated Referrals for Better Outcomes
Claim Clarity automates this process for efficiency, and enhances the accuracy of review outcomes. With an intuitive interface, the solution empowers users to proactively identify higher-risk claims early in the cycle, and allocate clinical resources efficiently to achieve better outcomes.
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A version of this article originally appeared in @Work, the official publication of Disability Management Employer Coalition, in July 2020.
