The array of managed care services that come together to help injured employees recover must be connected, collaborative and focused on the same goals to ensure the best possible care.
When an employee is injured on the job, there are multiple steps for the employer, the employee and their medical providers. It can be an overwhelming process. There are many elements for employers to consider to reduce costs and help injured employees recover. Having integrated, multi-disciplinary claims and managed care teams working together from the first report of injury to the moment the claim is closed helps employers control claim costs and ensures better care management for injured employees.
According to a study at Sedgwick, connecting managed care services, such as clinical consultation, medical bill review, case management, pharmacy management and utilization review on the same technology platform controls costs, and can help identify trends and create strategies to improve outcomes.
Determining the right level of care
Beginning with a 24/7 nurse line, the injured employee is triaged to determine if they need to be treated by a physician or whether self-care is more appropriate. If a physician is needed, the nurse will send the provider medical information such as where to send the employee for medication, imaging and therapy, which helps ensure the continuity of care going forward. Nurses answer questions, offer reassurance, evaluate the injury and use industry-proven guidelines to direct self-care, telemedicine or in-person care with a top-performing local provider.
Collaborating for the best possible outcomes
With claims and managed care teams operating on the same system, they have total visibility and can take steps as needed to help move the claim forward such as suggesting peer-to-peer consultations, or requesting nurse case management, behavioral health or return-to-work services. System triggers can be set up for services such as utilization review, surgery nurse services and pharmacy review.
Having real-time connectivity built into the system allows examiners and nurses to quickly exchange information and collaborate effectively to help injured employees achieve the best possible outcomes.
Decision optimization technology and preemptive utilization review techniques can also be integrated, helping to quickly identify when nurse case managers should intervene. By using Sedgwick’s decision optimization rules, we have seen a 31% decrease in the average referral lag time and an 8% decrease in average incurred medical costs.
An integrated system also helps bill reviewers keep a close eye on medical expenses, and improves speed, accuracy, savings and regulatory compliance.
Improving performance results
Supportive, collaborative services focused on the individual are proven to be effective for injured employees and their employers. An integrated claims and managed care program under one administrator is good for the employee’s well-being and it can make a positive impact on claim outcomes. Sedgwick’s clients moving from an unbundled program to an integrated program see improved performance results. Integrated clients outperformed unbundled clients by 11% to 13% over each year of a three-year analysis, and they see a 4% decrease in pending claim volume after choosing an integrated program, compared to a 7% increase for clients that unbundle.
To ensure the best possible outcomes, claims and managed care teams must remember that at the center of all the important services they provide is a person facing an injury or illness. Delivering a streamlined, connected solution ensures injured employees get the care they need to help them recover and return to work as quickly and safely and possible.
