Magazine article Risk Management

When Does Managing Medical Costs Pay Off?

Magazine article Risk Management

When Does Managing Medical Costs Pay Off?

Article excerpt

There are several cost-management products and services designed to control escalating medical costs, but determining which one is most effective can be difficult. However, the task can be simplified by analyzing one such program that has been in use for years.

Medical management intervention by registered nurses on workers' compensation cases is part of the injured worker's overall rehabilitation process. Now more than 20 years old, it is the grandparent of cost-containment services related to workers' compensation. Insurance companies began the practice by hiring industrial or public-health nurses to help injured workers in the hopes of returning them to work as soon as possible.

The reason this cost-containment program has not always been successful is that some of its key players do not understand how the process works and what goals it can realistically accomplish. Therefore, in determining the success of medical management of workers' compensation cases, it inevitably comes down to who is asked. Effective Medical Management

Medical management is most effective when it is implemented soon after the worker is injured. Once in effect, a well-run program will educate the injured worker, coordinate the various interests and parties involved with the injured worker and monitor and mold all the attitudes involved among the injured worker, employer and care providers. No doubt, medical management maintains positive attitudes among all the parties and focuses on returning the injured employee to work as soon as possible.

Effective medical management makes the most of available resources. The process saves money by decreasing initial and ongoing medical costs and, in man cases reduces the value of claims settlement. However, problems often arise because in many cases saving money is viewed negatively by the parties involved in the workers' compensation process. In other words, when it comes to medical care, it is not always a case of 'you get what you pay for.' High medical costs do not necessarily mean that the injured worker received high-quality care.

Medical management obtains appropriate levels of services for the injured worker at reasonable cost. Consequently, the injured worker obtains the best care and is thoroughly educated regarding his or her condition. The injured worker recovers faster, loses less self-esteem and is less likely to rely on a carrier, an administrator or on society at large for medical care.

Sometimes few, if any, of these positive results occur. This is due to the fact that problems arise from false expectations on the part of individuals involved in the workers' compensation process. For example, inexperienced or poorly prepared registered nurses may make subjective assessments based on objective facts or observation. When this happens, needs assessments and/or recommendations may be incorrect.

In addition, an injured worker may feel misled, confused or angered as a result of a nurse relaying erroneous information related to the claims process. Furthermore, the nurse may not understand the role of the individuals involved in the workers' compensation process, including the claims adjuster or administrator, attorneys and physicians. Inadequate knowledge regarding how these professionals interrelate in workers' compensation cases can chip away at the injured worker's positive attitude, resulting in a delay in the recovery process. …

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