These are just a few of the similarities between CM’s and LNC’s and why it makes perfect sense to be both. I can’t imagine being a WC CM without being a LNC nor can I imagine being a LNC without having the WC CM background.
These are a sampling of the types of job settings that I see WC CM’s and LNC’s co-exisiting in the same jobs.
For instance, my expertise is in TBI, SCI, Catastrophic injuries, rehab and case management. I have done catastrophic nursing for over 15 years and catastrophic case management for 11. I worked in a Traumatic Brain Injury and Spinal Cord Injury Rehab Hospital for 6 years, starting as a floor nurse and charge nurse & working up through the administrative ranks to Acute Case Manager and Clinical Nurse Liasian. My last insurance company position was as their “cat” nurse. I case managed the catastrophic cases, I got the really old, badly injured cases that didn’t appear they would ever be able to resolve and was basically told…..see if you can do something with this. This was my niche…
List the RED FLAGS: Prior Psych hx, Drug abuse x 10 years, 4 prior WC injuries Insistant on ER visit-could be drug seeking or could be wanting documentation to begin a paper trail for WC injury.
Remember, this occurred back in the late 80’s, early 90’s, when extended lengths of stays in rehab were the norm. A 6 month to 1 year stay was not unheard of.
Most TBI facilities use a system of rewards, when the patient accepts what has happened to them and “realizes” their
Basic things you and I take for granted like going to get our drivers license, looking for a place to live-he was a poor decision maker prior to the last 15 years, there had also been a lot of trouble over the 15 years which is why he was interdicted, etc.
Proving he could accomplish these steps would show that he had achieved the proper initiative, level of responsibility, etc it took to be able to live on his own. What took over 15 years to put in place, would take from 6-18 months to unravel and help him become independent again.
As he continued to be weaned off of services, the IW would have setbacks, which is why he wan’t just kicked out into the street with no services in place.
Discussion points-wc carrier will prolong settlement,
AALNC 2007 Conference Presenation The Total Package Color
The Total Package Dawn Vincent RN CRRN LNCC MSCC
What are the similarities and differences? <ul><li>WC Case Managers </li></ul><ul><li>Assimilate information, formulate opinions and present in a concise, orderly fashion. </li></ul><ul><li>Interpret medical records, MRI reports, etc. and relay to the adjuster, attorney, etc in easy to understand language. </li></ul><ul><li>WC CM’s are master coordinators. They coordinate medical appt’s with work schedules, PT schedules </li></ul><ul><li>Legal Nurse Consultants </li></ul><ul><li>Assimilate information, formulate opinions and present in a concise, orderly fashion. </li></ul><ul><li>Interpret medical records, MRI reports, etc. and relay to the adjuster, attorney, etc in easy to understand language. </li></ul><ul><li>Legal Nurse Consultants are master coordinators . They assist in coordinating expert witnesses, depositions, </li></ul>
Types of job settings: <ul><li>WC CASE MANAGER </li></ul><ul><li>WC Insurance Company </li></ul><ul><li>Case Management Co. </li></ul><ul><li>Attorney’s offices </li></ul><ul><li>Government Offices </li></ul><ul><li>Independent CM’s </li></ul><ul><li>Hospitals </li></ul><ul><li>Large industry settings </li></ul><ul><li>LEGAL NURSE CONSULTANT </li></ul><ul><li>Attorney’s offices </li></ul><ul><li>Insurance Companies </li></ul><ul><li>WC Insurance Companies </li></ul><ul><li>Independent LNC’s </li></ul>
Find a niche for your special expertise and market that…. <ul><li>Examples of these could be: </li></ul><ul><li>High Risk Obstetrics Claims-believe it or not, can be work related-injured while working, becomes related, </li></ul><ul><li>Cardiology Claims </li></ul><ul><li>Traumatic Brain Injury </li></ul><ul><li>Spinal Cord Injury </li></ul><ul><li>Catastrophic Claims in General </li></ul><ul><li>“ Major Claims” (many insurance companies have Major Claims units- for their cat claims, over a certain $$ amount or a certain type of injury triggers it to go to this unit) </li></ul><ul><li>Number crunching-you can assist claims adjusters with setting reserves by figuring what the injury is going to cost them for the life of the file </li></ul>
How being a WC CM + LNC = Positive work experience for you <ul><li>Combining your experience as a WC </li></ul><ul><li>CM and a LNC you bring to the table a </li></ul><ul><li>bevy of skills that many companies </li></ul><ul><li>would have to hire at least 2 people to </li></ul><ul><li>fulfill the job set for. You have it in 1 </li></ul><ul><li>person……..YOU! </li></ul>
Sample Case: <ul><li>Let’s look at an example of how a WC CM that is also a LNC impacted a file that had been case managed for 15 years by a vendor case manager with no end in site. Cost of vendor case management: $32,000/yr for total of $480,000.000 over 15 years. </li></ul>
Sample case demographics: <ul><li>42 year old male, 27 at time of injury. Hit in the right side of head with a board that dropped from a height of approximately 5’, clipping the right side of his head. It was a ¼” sheet of plywood cut into a 2’ x2’ section (to cover a window). It was a glancing blow, there was no LOC, he did not fall to the ground, slight 1” laceration to the scalp that did not require stitches. </li></ul>
Demographics continued <ul><li>EE had a hx of numerous prior psychiatric admissions for violent behavior and a hx of drug abuse x 10 years. He had 2 minor children and was married at the time. He had 4 prior WC injuries. IW insisted on going to the ER for this minor injury. </li></ul>
ER VISIT <ul><li>Initial ER visit 1” laceration, bleeding controlled with pressure, no sutures. AOx3. Discharged to home with instructions to use ice to head if swelling noted, tylenol for pain. </li></ul><ul><li>The next day IW and wife were back at ER, she was complaining he was having violent outbursts since injury (un-witnessed) & that this was not like him (no one in WC or medical field was aware at this time of his previous admissions to psych), this continued on for several days with frequent trips to ER and diagnosis was changed from contusion to TBI. This was the beginning of IW building a WC case, and of a IW misguided by the legal system, the medical system and eventually his own family. </li></ul>
Rehabilitation or life in prison? <ul><li>After thousands of dollars in tests were run at the expense of WC, (MRI’s, CT’s EEG’s, EKG’s, etc., etc) the doctor’s still found no reason for IW’s violent outbursts. It was decided to try inpatient rehabilitation to see if any of his behavior issues could be managed in that setting. </li></ul>
Cont. <ul><li>After 14 months of inpatient rehab, IW was scheduled to be discharged to return to work full duty and his attorney had him transferred to another rehab facility in another state that specialized in TBI. At this time, IW was deemed recovered and able to RTW FD and had no continued diagnosis that supported this transfer. He had a simple scalp contusion and laceration that had been upgraded to a TBI </li></ul>
<ul><li>because his wife said he was having un-witnessed violent outbursts. </li></ul>
15 years of cost leakage for work comp company = need for LNCC/WC CM <ul><li>The IW spent the next 15 years being shuffled from one TBI facility to another till 2003 when WC+LNCC CM received file to case manage. </li></ul><ul><li>IW had Lost job </li></ul><ul><li>Social Security </li></ul><ul><li>Became interdicted & step-mom took over all aspects of his life, </li></ul><ul><li>Wife divorced him </li></ul><ul><li>Children grew apart from him </li></ul>
Cont. <ul><li>Lost 2 homes he owned </li></ul><ul><li>He had also claimed that the blow to his head injured his neck and back and had been receiving chiropractic care x 15 years, physiatrist care x 15 years, neurology x 15 years, pharmacology x 15 years, psychiatric care x 15 years, he had joined an elite health club under WC’s dime for the past 5 years and was getting his BP medication, ED and other unrelated medications paid for under WC. </li></ul>
Turn the case around <ul><li>Injury occurred in 1988, LNCC/WC CM took over case in 2003 from vendor CM’s </li></ul><ul><li>Attended the monthly staffing meetings & made presence known to current facility-questioned most of their modalities-they were in a status quo mode-getting paid a lot for doing a little and adding a lot of fluff. </li></ul><ul><li>Made sure it was understood EVERYTHING had to be approved through CM-nothing could just be </li></ul>
Be tough.. <ul><li>ordered and done, had to be approved first, if it wasn’t medically necessary and related to original injury, it didn’t get done. </li></ul>
Get Active, Move that File <ul><li>Start finding proper specialists for IME’s </li></ul><ul><li>Get Voc involved to facilitate RTW – even after 15 years-this facility was using their own vocational rehabilitation people-LNCC/WC CM didn’t feel they were pro-active and aggressive enough, very lacsidaisical in their approach to RTW, took months to help IW complete job application. LNCC/WC CM got State Voc involved to assist in RTW, job coaching, etc. </li></ul>
Always be thinking <ul><li>Get Social Worker started on helping finding proper home placement-IW’s will need a place to live if family is not an option, in many places Section 8 has a 1-2 year waiting list so this is something to think about immediately, SW’s aren’t! </li></ul>
Document, Document, Document <ul><li>While implementing all these changes, make sure you are documenting very well. You are rocking the boat! This is where the cross between LNC and WC blend so well, the WC CM knows exactly what is needed for the IW and the file and the LNC part of her/him knows what is within the legal realm and within work comp statutes, etc. This is the total package. </li></ul>
<ul><li>Neuropsych IME concluded that IW never had a TBI, at most, he had a concussion-should have RTW in 1988, however he now has a “Learned Brain Injury” from being in TBI facilities for years </li></ul><ul><li>Worked with IW’s treating PM&R over a 2 yr time span and was able to get him to say that back and neck NOT related to original injury after he read original neuropsych eval of 1993 and then IME of 2005 and was able to get him to say he may need up to 6 PT visits per year, 2 PM&R visits per year for medication management & weaning x next 3 years; that in turn did away with chiropractic treatment, health club membership; </li></ul>Back to the Case…..
Knowing which key to use to unlock the mystery…. <ul><li>The neuropsychological evaluation </li></ul><ul><li>This held the magic key for this file for almost every aspect- </li></ul><ul><li>PM&R-based on the findings-convinced this MD to reverse his diagnosis & tx plan & WC will not owe for this IW’s neck and back for the rest of his life </li></ul><ul><li>Psych-based on the findings-irrefutable findings that proved that IW had pre-existing psych issues and violent tendencies that were NOT produced by the mild blow to the head. WC will not continue to owe psych for the rest of IW’s life. </li></ul>
Cont. <ul><li>Return to Work </li></ul><ul><li>It was determined IW was able to RTW with assistance from voc and job coaching-he eventually RTW at 2 jobs! </li></ul>
The Process….. <ul><li>SocioEconomic </li></ul><ul><li>IW wanted his life back-a home/appt, a driver’s license, a car, his right to make decisions again </li></ul><ul><li>It was determined that the neuropsychologist would be in charge of determining a plan set on a 6 month timeline with specific goals to be met for IW to achieve in order to “get his life back” and be discharged from the inpatient TBI setting. </li></ul>
Baby Steps <ul><li>Get a job and keep it for at least 3 months </li></ul><ul><li>Proving he could maneuver the city on public transportation without assistance from staff or case management for those 3 months </li></ul><ul><li>Then, he would be allowed to get a drivers license </li></ul><ul><li>After obtaining a driver’s license, he would be allowed to drive his parent’s spare truck after obtaining proper insurance and he would be allowed to park it on hospital property. He would be allowed no tickets or accidents. </li></ul>
Cont. <ul><li>After driving for 2 months and working now for 5 months, he would be allowed to look for a place to live & it would have to meet with parents approval, hospital staff approval & CM approval </li></ul><ul><li>After all these steps were accomplished, and he lived on his own for a few months, then reversing his interdiction would be looked at. </li></ul>
Benefits for IW <ul><li>Regains independence </li></ul><ul><li>Gives IW a new lease on life, a new start </li></ul><ul><li>Able to feel productive, worthwhile, he liked knowing there really wasn’t something wrong with him after he got over his initial anger of loosing 15 years of his life. </li></ul>
Benefits to Insurance Company <ul><li>Cost Savings: </li></ul><ul><li>Initial cost savings were by using internal CM vs Vendor CM-$30.00/hr vs $125.00/hr </li></ul><ul><li>Negotiated monthly price for inpatient rehab. Current mo/pr was $20,150.00. Neg to $15000. Cost savings of $61,200./yr </li></ul><ul><li>Utilized PPO providers for transportation </li></ul><ul><li>Referred IW to all community liaison resources for assistance. </li></ul>
Cont. <ul><li>Purchased Health Club Membership for $219.14/yr x 1 yr to cut costs of aqua therapy 3 x wk @ $125.00/visit cost savings $375.00/wk x 6 wks = $2250.00 </li></ul><ul><li>Got PM&R to reduce chiro or PT to 6 visits per yr. Iw had een treating with chiro typically 3 times/wk x 15 yrs. Cost savings of $100./visit x 1 time avg per wk x 52 wks = $5200.00 </li></ul>
Winding down…. <ul><li>Had IW evaluated by urologist for impotency issues and causal relationship. Found not causally related to injury but to tobacco use, thus we were able to discontinue paying for Levitra, Viagra and Cialus, Cost savings of cost of medications: Viagra $268.97 x 30 tablets, Cialis $269397 x 30, levitra $253.97 x 30. Yearly cost saving of ONE of these medications is $3239.64 </li></ul>
Cont. <ul><li>Once he was discharged, minimal support services continued to be supplied by hospital for $1500.00/month to be weaned over a 6 month period </li></ul><ul><li>Soft savings not including medication $76514.64 annually </li></ul><ul><li>Over future life of file: $76514.64 x 30 years = $2295439.50 </li></ul>
We can make a difference, we do matter <ul><li>Clearly document what you do, how you do it-the CM on this example did not end up being taken to court by the IW’s attorney-he had nothing to take her to court on.. </li></ul>
Cont. <ul><li>Ex: Neuropscyhological IME is scheduled with Dr. A for August 6, 2004 to for neuropsychological examination. Last neuropsycholological exam was performed Dec 12, 1993 by Dr. B. IW’s injury is 14 years old and reassessment is appropriate & medically necessary at this time to determine IW’s level of functioning. IW has been notified by reg. mail and certified mail # 70041160000097634716 with 14 days notice per LA State Statute as has his attorney, Lawrence L. Lawyer, cert. mail # 7004116000097634715 </li></ul><ul><li>Continue to document every detail of what you do, who you talk with, who you deal with, what you mail and you will be able to come back in 1 wk, 1 month or 5 years and know what progressed </li></ul>
Assisting the attorneys…as the LNC <ul><li>LNC’s who have been WC CM’s have a distinct advantage in helping plaintiff attorneys, they can assist with helping lay the ground work for their cases-they know the way the WC system works, they can anticipate the WC companies next move or what their response might be. </li></ul><ul><li>Decipher the medical records and anticipate the next medical move of the WC Carrier </li></ul><ul><li>Assist with locating expert witnesses </li></ul>
Moving toward resolution… <ul><li>Always remember, the ultimate goal in any WC file is to move the file toward resolution-RTW is always first and foremost goal. The fine line for the WC/LNC CM is dependent on which side of the fence you are working on…. </li></ul>
The End <ul><li>Thank you and please remember to complete the session evaluation. </li></ul><ul><li>If you have any questions, please feel free to contact me at: </li></ul><ul><li>DV Consulting Co. LLC </li></ul><ul><li>Dawn Vincent RN CRRN LNCC MSCC </li></ul><ul><li>Houma, LA </li></ul><ul><li>985-876-7801 </li></ul>