Claims Wire: Why Expert Medical Management Matters

January 26, 2022 • Previsor

Have you ever filed a workers compensation claim? You might know that it’s your work comp carrier’s responsibility to pay medical costs for compensable on-the-job injuries. However, if you haven’t had much claims experience, you might not know that there’s a lot more that goes into claims management than simply paying the bills.

From the moment you report a workplace injury, our claims experts work with you to ensure your employee gets the right level of care quickly. Then, we follow the claim throughout the treatment process to ensure the employee is doing well on the road to recovery.

Claims costs can have a significant impact on your premium. That’s why it’s in everyone’s best interest to work together toward the best medical outcomes. Here’s one example of the difference expert medical management can make.

A heavy lifting injury gets complicated

Earlier this year, we received a claim that a worker’s shoulder was sore after unloading something heavy. He received medical treatment but began to lose grip strength and feeling in his arm over the next few days. He called our claims representative who pressed to get the worker another appointment the following day.

Seeing the increasing complexity, the claims representative requested that a nurse case manager join the claim team. Reevaluation showed a possible nerve condition, which prompted further testing. When testing showed degenerative changes in the worker’s spine, doctors recommended an urgent evaluation by a spine surgeon. Our nurse case manager contacted eight surgeons to get him an appointment as quickly as possible.

At this appointment, things became more complicated. The surgeon felt the exam did not match the diagnostic testing results. They suggested a cervical fusion but recommended further specialist evaluation.

The nurse case manager facilitated evaluation by a neurologist and upper extremity specialist, as well as more testing. All the specialists discussed the case and decided to proceed with the emergency fusion surgery. They scheduled a pre-surgery brain MRI to check for major neurological deficits.

A surprising twist

The nurse case manager pulled in our medical director to consult, and our team decided to seek out an urgent second medical opinion. We did a case review with another specialist who disagreed with the need for emergency surgery. Meanwhile, the pre-surgery MRI revealed something shocking. The worker – in his early 40s and otherwise healthy – was having these medical issues because he’d had a stroke.

We canceled the emergency surgery, and our nurse case manager arranged for expedited follow-up stroke care with the worker’s primary care doctor. Of course, the worker and the policyholder had many questions about the outcome and care plan going forward. Our team discussed all their concerns to ensure they felt comfortable. The worker was grateful he’d avoided unnecessary surgery and that the stroke had been discovered.

Physician discusses medical treatment with patients

Your medical management team matters

It’s uncommon for someone so young to have a stroke, so it’s no wonder that it wasn’t caught sooner. If not for the team of experience claims professional working together on behalf of the employee, the outcome of this claim might not have been so positive. That’s why choosing a work comp carrier with expertise in claims management is so important for business owners.

Learn more about our medical care management strategies.

January 26, 2022
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