FCM / TCM

Upon referral to Novare, the account/referral source can rest assured that the medical aspects of the claim will be handled with expertise by field and telephonic nurses who are well versed in the medical treatment guidelines of their respective state.

Once a referral is received, a secure link is available upon request to transmit any amount of claim documents and/or medical records. Case managers are provided the referral information and documentation expeditiously to prevent delays in the initiation of service. Next, the case manager will review records and make appropriate contacts within twenty-four hours. Experienced case managers work with adjusters to assist in bringing about the most appropriate and cost effective solution to barriers preventing return to work and achieving maximum medical improvement.

Novare nurses are professionals who are not measured based on their ability to bill, but rather their ability to move claims in a positive direction. Our case managers approach injured workers holistically, considering both comorbidities and socioeconomic hinders to recovery. Additionally, case managers educate providers on the responsibilities facing the workers compensation carriers versus private health insurance. Using this holistic and educative approach often promotes more positive outcomes with a shorter days of disability noted.

Initial and follow up reports may include,
but are not limited to:

Discharge planning begins with the initial interview. Nurses obtain a medical and surgical history, as well as history of present and past injuries and treatment, psychosocial, education, and military status. Additionally, case managers will note if SIF and/or subro are possible on the file. Case managers communicate effectively and efficiently with both employers and adjusters to establish goals which are documented on each initial and progress report. State guidelines/ODG are also included on initial reports to provide days of disability estimation as well as appropriateness of the plan of care.

Progress reports include significant updates, changes to the plan of care or return to work expectations, availability of modified duty, medications, current barriers, and a case management plan to progress the file.

Task assignments are also available and typically utilized to secure missing pieces of information, improve specific communication with a provider or injured worker, medication reviews, MSA reviews, or when there is a specific, short term issue affecting compliance.

Novare’s Telephonic Case Management Program is designed to meet the program
objective. Novare recommends that nurse involvement be an integral part of any claims medical management program. The Novare Telephonic Case Management Program is developed based on the needs of the customer and is a living, breathing program that is subject to change based on claims data and evolving needs of the customer.

Claims that will benefit from Telephonic Case Management
(not all claims are appropriate for nurse intervention)

Catastrophic Claims
Hospitalization of injured worker
Lack of clinical objective findings
Uncooperative providers
Expanding symptomatology and/or diagnosis/body parts
Referral to a specialist physician
Lack of consistent modification of work status based on the objective medical findings of the injured worker
High volume of medical treatment requests
Evidence of comorbidities

TCM ACTIONS

Assist the Client/Adjuster in addressing causation and questions of extent of injury (pre-existing conditions and/or comorbidities).
Assist the Client/Adjuster in identifying anticipated appropriate medical treatment through use of evidence-based medical guidelines for the known diagnosis(es). Action results in more accurate reserve setting for the Client/Adjuster.
Provider contact. Confirm the mechanism of injury as described by the injured worker, medical diagnosis, proposed treatment plan, work status, next scheduled appointment and request medical documentation. If the injured worker has been removed from work, a discussion will be initiated at the first contact with the Provider regarding the appropriateness of the off-work status and the availability of modified duty.
Aggressive pursuit of resolution of treatment and full duty release of the injured worker.
Promptly communicate all medical and work status information to the Client/Adjuster and/or employer.
Identification of pharmaceutical over-utilization and establishment of plan of action.
Assists the Client/Adjuster in identification of increased claim costs triggers which may include:
- Short-term employment
- Prior lost time claim
- Low job satisfaction
- Disproportionate illness behavior
- Early request from the injured worker for a second opinion or to change treating providers
Review claims for the appropriateness of Field Case Management referral. Telephonic Case Manager will act as the medical point person for the FCM for the duration of the FCM assignment. Perimeters may be further established specific to the Client.
Participates in Claim File Reviews as scheduled by the Client.
Reviews claims with Client/Adjusters to determine appropriateness of IME. TCM will participate fully with the Client/Adjuster in coordinating the examination including ensuring that all available medical documentation is available for the IME Physician and preparation of IME questions.