Saving money

When I go shopping at my favorite clothing store and  purchase something fabulous on sale, I love to tell my husband how much money I saved him.  He usually rolls his eyes, not totally buying that he "made" money by my spending it.  He took this picture of me shopping while we were on vacation - he was bored.

I have seen that same skeptical eye roll from claims managers when discussing the savings they can reap by using case management on their files. So let me tell you how just this week Stacy Mathis, RN saved one of our customers $75,000 with only 8 hours of case management services.  

A file was referred with a date of MVA October 2013. The claimant was driving a work vehicle and was rear ended.  He reported no injury at the scene and continued working regular duty.  In June 2014 he filed a work injury claim citing back pain for several months stemming from the MVA.  Case management received the file July 2014.  Red flag #1, delayed reporting.  Stacy arranged for evaluation and treatment of his back, and then the claim grew - he said he had fallen "due to his back pain" and hurt his knee.  Red flag #2, incomplete reporting.  AND his orthopedic surgeon is recommending knee surgery, which he wanted covered under his claim.

So follow along...The claimant's physician had recommended surgical repair of an ACL tear and meniscal tear secondary to a fall, as the result of back pain, stemming from the MVA.  Are you keeping up? Now it's not unusual for a claimant's personal physician to be sympathetic and go along with the patient's line of reasoning.  But in workers compensation the law requires "objective findings," and his personal orthopedic choice did not provide any objective findings, but did relate the knee surgery to the MVA from last October. 

Stacy gathered medical records and coordinated an Independent Medical Evaluation with an orthopedic specialist in order to address causation.  It happened Monday of this week.  A thorough physical evaluation was completed, along x-ray views of the knee.  While there was evidence of trauma to the knee that would correlate with a fall, there were significant preexisting chronic arthritic changes as well.   The final opinion was that there were no objective findings that he could relate back to the original injury.  Furthermore, he could not recommend surgical intervention for any of the present findings.

Needless to say, the carrier was pleased with the opinion.  If the claimant wants to pursue surgery with his own orthopedist, he can certainly do so under his own health insurance.  No surgery is cheap these days, but ACL reconstruction is a very costly procedure.  The hefty price of an IME documented the claim and was well worth the expense - and the expense of utilizing Case Management is justified with real savings value. 

So I think Stacy should go shopping and tell her husband she saved $75,000 this week!