Pre-Claim Nurse Triage a Little Used Best Practice for Workers’ Comp

Though large, self-insured companies have been using it for years, pre-claim nurse triage has not yet been wholeheartedly embraced by workers’ compensation carriers, according to Brian Cullen, managing director of Triage for Medcor, an outsourcing service that works to improve outcomes and reduce costs.

“Claim people are so sure that they have everything done with the claim, but they don’t quite get pre-claim first aid screening, which all the big companies have already proven works great for the 17 years we’ve been doing it. It’s fascinating to watch an industry wake up to this best practice,” said Cullen.

According to Cullen, Medcor works with about 15 carriers now and says it’s still in the very early stages of the adoption curve. Captives have embraced pre-claim nurse triage while state funds have also been slow to adopt the system.

He said a nurse answers the phone directly and after obtaining a name and location will begin series of questions on defining the injury. The system can handle multiple injuries due to a patent the company has that enables parallel triaging of multiple injuries simultaneously.

Initially, the nurse will try to rule out a call to 911.

“Literally, one percent of all calls we take result in a recommendation of 911,” Cullen said.

One insurer that sees benefits in using early claims triaging is Secura.

“We have been doing it since late 2011. We were fully engaged with it by about the middle of 2012,” said Tony Brecunier, director of workers’ compensation for Secura. “We had some of our agents who had a 24/7 nurse triage on some of their program accounts, and were telling us that they were seeing benefits of lesser claims reported, better reporting, lower lag time reporting.”

Brecunier said that while Secura’s workers’ compensation program had reactive programs in place, such as bill review and a pharmacy vendor, the company recognized an opportunity to improve the outcome before an injured worker is treated.

Medcor pioneered telephonic triage, according to Cullen.

“We literally now have taken 1.7 million phone calls in 17 years, and we’re taking about a thousand a day with a call center staffed with RNs,” said Cullen. “We have algorithms that we’ve homegrown, we own our own software company,” he said.

The company uses big data to continually improve the questions. He offered an example where an injured worker strains his back and isn’t sure what to do.

“We call our service ‘decision support,’” said Cullen “We don’t use the word diagnosis because that implies a site visit face to face, where a nurse is poking and probing and doing something that’s the practice of medicine. We use registered nurses, but it’s really the systems and these algorithms that are geared specifically to workplace incidents and answering whether more medical attention is needed.” He said that if the system determines medical attention is needed a pop-up box offers suggested network providers from a list of more than 160,000 locations that are pre-programmed into the system.

It takes the onus off of the supervisor to make a potentially life-altering decision and also allows for immediate documentation of the injury claimed.

“The beauty of this is not only does the supervisor not have to make a difficult medical decision for which they’re not so well qualified, but we record every conversation,” Cullen said. “The spontaneity of the communication where preferably a supervisor has made the initial call, introduce the injured worker, hands it off for a one on one with the nurse and then debriefs at the end of the call.”

Brecunier says Secura has seen a reduction in claims.

“We have seen a reduction in all types of situations,” the workers’ comp director said. “While it’s hard to measure…we know that when we look at the calls that are made to the 24/7 triage…about 42 percent of those folks go back to work without ever making a claim,” said Brecunier.

The advantage of a nurse hotline, he said, is that the injured worker knows he or she is speaking with a medical professional who can provide reassurance that a back strain will typically resolve in a day or two and if it doesn’t then further treatment can be sought.

Though Brecunier can’t say for sure that it has limited fraud in Secura’s program, Cullen said pre-claim triage has the potential to reduce fraudulent workers’ compensation claims.

“It’s [the initial call recording] has been upheld many times in litigation. What our clients tell us is that the spontaneity of this call, plus the digital recording, tends to reduce the temptation for people to attempt to claim something that didn’t happen or more than what really occurred,” Cullen said.

Improved customer service is a major benefit, both experts said.

Cullen provided an example involving a mine in Arizona. An injured worker complained to supervisor that while erecting steel he felt that he had a very sore jaw. The supervisor called the risk manager, who was located in another state. The supervisor was told to call the nurse claim triage number. The nurse suggests 911 because the symptom he complained of could be a symptom of a stroke or heart attack. The EMTs arrive and order him air lifted because he was having a heart attack. He had open heart surgery as a result.

Though not an injury sustained at work, unless he fell and hurt himself or someone else at the site, Cullen said it was evidence that pre-claim nurse triage can minimize the number of unnecessary claims and reduce workers’ compensation costs.

Besides the potential costs savings, improved customer service to the insured and a reduction in claims, there are additional benefits.

“Obviously, there is an immediate recording of the call so we always have that to pin down what exactly happened, and when, and what body part is affected,” said Brecunier. “We think that helps prevent a little bit of those creeping injuries.”

In addition, the insured gets the benefit of a portion of the paperwork being done for them.

“Their supervisors don’t have to fill out a full first injury report because we’re able to get all that information and do it for them,” said Brecunier.

The insurer has seen the biggest impact on back claims.

“We’re able to track, by body part, the number of calls that go into the nurse hotline and then the number of those where they actually then went out and sought treatment. It’s difficult to put a price tag on how much we really save but we know that 48 percent of the calls that came in regarding the back…no claim was made,” said Brecunier. “How many of those could have been the person already walking around with a herniated disc that now didn’t go get an X-ray that had showed up and it was made work-related, you just never know.”

Besides reducing the number of workers’ compensation claims and costs because not everybody will need emergency room treatment, the system also helps to improve productivity.

“The real value is the $3,000 claim that doesn’t become $30,000, because everyone did the right thing right away,” said Cullen. “We had up to 4,000 phone calls last year. Of all the phone calls we took [with Secura], 46.6 percent went back to work with no need for outside medical…almost half of the phone calls we receive result in no need. That’s why we make the statement that we think we probably cut claims by 25 percent. It’s a reasonable number. We take a hundred phone calls; 46 of them go back to work.”

Cost savings per claim, according to Cullen, is about a six to one return on investment. Actuaries report that while 95 percent of the calls Medcor takes are medically-related, five percent are indemnity-related.

Considering that nurses are considered the most trusted healthcare providers according to a Gallup poll conducted in 2013, a white paper released by Coventry earlier this year noted that leveraging trusting relationships with nurse case managers can boost patient engagement.

Secura considers nurse pre-claim triage a competitive advantage.

“There are multiple companies that offer the service. We know, from our partnership with Medcor, that back in 2011 we were like the third insurance company that had joined them and I know they’ve got several more than that,” said Brecunier. “But it hasn’t opened up the floodgates like we kind of thought it would.”

“As a director of workers’ compensation claims, I’d like to say that it is responsible for our great loss ratio,” Brecunier said. “There’s obviously a lot of other things from my brethren at underwriting and risk management that go into that, but we really, truly feel that it has been very beneficial to our insureds, our agents and Secura.”