Team approach eases employees back to work
It also helps if you know how to schmooze’
It’s not impossible to get a physician’s attention when you have no financial carrots to dangle, but it’s as close to impossible as it comes. Disability case management teams are often the best chance an employer has to get a valued employee back to work after illness or injury, but the job of those team members is unique in the world of case management.
"I’m not in a position to approve payment for the physician’s services or any other medical services or medical equipment, which makes my job challenging. The health care side calls all of the monetary shots," explains Janet M. Frontera, RN, BSN, CCM, A-CCC, medical consultant for the Pittsburgh claim office of CIGNA IntegratedCare. "A workers’ comp case manager might be able to pick up the phone and arrange an MRI for a patient, or authorize six more physical therapy visits; I can’t."
What Frontera does, with the help of the other members of the disability case management team at CIGNA, is develop an organized approach to managing each disability claim with a goal of returning the claimant to full- or part-time employment whenever possible.
The minute a disability claim comes into CIGNA IntegratedCare, a case manager is assigned to review it. If the claim seems straightforward, for example, a short-term disability due to a fracture, the case manager may be the only one to work on it. However, if the diagnosis or prognosis is unclear, the case manager calls in the other members of the disability case management team — the occupational consultant and the medical consultant.
"I have to know when to call in our consultants and also how to take their expert opinions back to my desk and use them to make a claim decision," explains Kristen L. Stagliano, BA, case manager for long-term disability at the Pittsburgh claims office of CIGNA IntegratedCare. "In addition to the occupational consultant and the medical consultant, we have economic and Social Security consultants on staff to help claimants with terminal or long-term progressive diagnoses file for benefits and plan for their financial future."
Case managers begin by contacting the claimant and the physician to assess the claimant’s functional capacity. "If the claimant is preparing to return to work, or seems motivated to return to work, I bring in the occupational consultant to work with the claimant and the employer on any return-to-work issues, such as modified duty or workplace modifications. If the claimant has a comorbid psychiatric condition, or the medical situation is unclear for other reasons, I call in the medical consultant."
Good customer service
After the consultants have been called in and done their initial evaluation of the claimant, the team sits down together to set goals for the claimant. "This approach not only helps us work through the claim efficiently, but it also gives the claimant several other contacts here at CIGNA. If the claimant has a pressing question and the case manager is not available, there are two other professionals familiar with the claim that the claimant can talk to," Stagliano says. "It’s wonderful for customer service. Claimants don’t have to constantly retell their stories."
The team approach works, say Stagliano and Frontera, because each team member brings a unique perspective and set of skills. "The case managers have ownership of the claims and are experts on understanding the policies and issuing benefits," Frontera says. "However, the early intervention of the nurse and occupational consultants are essential to getting claimants back to work."
For both the occupational consultant and the medical consultant, success depends on their ability to build a rapport with the interested parties. "My first contact, after reviewing the file and the medical record, is with the claimant," says Shelley S. Mayhak, MEd, CRC, CDMS, an occupational consultant for CIGNA IntegratedCare in the Pittsburgh claims office. "I introduce myself and my role. I’m very honest right up front that my goal is to get people back to work. The claimant’s reaction to that statement helps me get a perception of their own goals. Most people want to go back to work."
Mayhak describes herself as a "cheerleader." She explains, "If I have information in the medical record that the claimant has the ability to return to work, I ask for permission to contact the employer about return-to-work issues. And when I get on the phone with the employer I start selling. I tell them, This employee is really anxious to return to work.’ The earlier on in the claimant’s disability, the more potential there is for a successful return to work, and the less likely that the employer will have found a replacement."
If a claimant seems reluctant or unsure about returning to work, Mayhak explains that CIGNA provides some financial incentives in most of its disability contracts. "Essentially, I explain to them that they may make be able to return to work and still qualify for a partial or full benefit. It’s less scary to the claimant if we keep the claim open just in case they return to work and have a relapse."
"I try not to be judgmental," she adds. "Sometimes, you catch someone on a bad day. Maybe the claimant is a cancer patient who has just received chemotherapy. I try to feed them some work incentives and suggest they take time to think about it. Often, I call back in a few weeks and the claimant is much more motivated to return to work. Sometimes, the claimant calls me a week later because they are feeling better and can’t wait to get back to work."
Mayhak uses the rapport she develops with claimants to encourage them to keep in contact with their supervisors and co-workers. "Often, the claimant is uncomfortable or reluctant to contact their supervisor, especially if they’ve been out for awhile. I spend time encouraging the claimant to go ahead and make that call."
Of course, sometimes the claimant’s injury or illness means that a return to work requires special accommodations. "It’s important to have as detailed a job description as you can get from the employer. You have to know exactly what tasks are necessary and work with the employer, the claimant, and the physician to determine whether or not the claimant can do the required work," says Mayhak. "The job description may call for a medium work level requiring lifting of 20 to 50 pounds. The physician may say the person can’t do that job because they aren’t able to lift. But it may be possible for a co-worker to do the lifting."
In addition, Mayhak often calls in a physical or occupational therapist to conduct an on-site job analysis. "The local treating therapist is the best person for the job because they are best qualified to know the claimant’s abilities and limitations."
In many cases, very inexpensive workplace modifications can solve a return-to-work problem. "For example, for an individual with a herniated disc in her neck who works in a position where she spends a good deal of time on the phone, something as simple as a headset, which the employer may already have available, may be all it takes for the physician to release the claimant and make it possible for the claimant to do her job."
Picking up the tab
At other times, CIGNA finds that getting the employee back to work requires reaching into its own wallet. "We had a young man who was injured and ended up in a wheelchair. The health plan provided a wheelchair, but he hadn’t yet developed enough upper body strength to lift the chair in and out of the trunk of his car and it was preventing him from returning to work," recalls Frontera. "I asked the health plan for a second wheelchair, but was told that one chair was a necessity and two was a convenience she couldn’t fund. After a meeting with team members and discussion with the employer, it was decided we would fund the cost of a second chair for this patient, who was very motivated to return to work."
Frontera has the unenviable task of developing relationships with physicians in order to get the claimant the care necessary to facilitate that return to work, which is the team’s ultimate goal. It’s not easy to gain a physician’s cooperation when you have no financial clout to get his or her attention. Here are some strategies Frontera says have worked well for her:
• Know the file inside and out. "I need to know every provider the claimant is seeing and review each provider’s progress notes," she says. "I may find that the claimant is seeing a therapist for depression and the treating physician doesn’t know it. I may find that claimant has a comorbid condition that the treating physician is unaware of and not treating."
• Do your research. "I often use the Internet to help me gain a better understanding of a patient’s condition," Frontera says. "I have my favorite Web sites that have been recommended by our physicians as providing reliable medical information on new drugs and new therapies. If the claimant’s condition is unfamiliar to me, I’ll get online and gather the latest information available before contacting the treating physician."
• Contact the claimant first. "Without the cooperation of the claimant, my task becomes even more challenging," Frontera notes. "Generally, the case manager tells the claimant that I will be calling, to smooth the way for me. I contact the claimant to develop a clear picture of the situation — the claimant’s spin’ — before contacting the treating physician. And, from the very first contact, I establish a relationship with the claimant so we can talk about return to work and we work together to set realistic goals for that return to work."
Frontera conducts a medical interview with the claimant over the telephone. She gathers information on the patient’s medical history, current medications, current therapies, and activities of daily living, as well as the claimant’s personal perception of disability and expectations for return to work.
She may also enlist the claimant’s help making contact with the treating physician. "I’ll tell the claimant that I’ve faxed their physician a list of questions that I need answered in order to get them their benefits and ask the claimant to give the physician a call."
• Set up an appointment with the physician. Cold-calling a physician is never a good idea, cautions Frontera. "The physician has so many patients to treat, they might not even be able to recall the claimant you’re calling about. Set up an appointment time with the physician’s office staff and fax a list of questions ahead," she suggests.
By taking those two steps, not only will the physician have the claimant’s chart close at hand and be ready to answer your questions, but you will also have shown respect for the physician’s time. "Physicians appreciate it if you’re organized and get straight to the point. Their time is very limited. You’ve proven yourself by being prepared. You get on the phone, you ask your questions, and you get off. You’ve been quick and to the point. It helps get a plan in place that you and the physician agree on. If you want the physician to talk to you, make it as easy as possible," Frontera suggests.
Flex-time
And, be flexible with your time, she urges. "Making yourself available to the physician is essential. If you’re on the East Coast setting up an appointment with a physician on the West Coast, suggest that you catch them before they start their office hours. Try catching physicians on their lunch hour, or offer to stay late and talk to them."
• Show your appreciation. "The first thing I do when I get on the phone is thank the physician in advance for speaking with me. And, I never get off the phone without thanking the physician again and asking for permission to speak with him or her again as the disability claim continues," Frontera says, adding, "I rely on knowledge and experience as a nurse to help me develop an effective working relationship with the treating provider, which usually results in positive outcomes for everyone involved, especially the claimant. Still sometimes it’s necessary to schmooze’ a bit to gain a physician’s cooperation."
Another trick Frontera finds useful is to ask for the physician’s help understanding the claimant’s medical condition. "It’s not because I don’t understand the claimant’s condition, it’s just a useful tool for developing a dialog with the physician," she says. "It puts the physician in the position of using their medical knowledge to clarify things for me, and as the conversation develops we discuss the effectiveness of current treatment, functionality of the claimant, and prognosis for return to work. Most physicians open up and share tons of information."
• Be helpful. Many times a claimant is being seen by more than one provider and none of the providers is aware of the others, notes Frontera. "I’ll let the primary physicians know there is another physician involved and try to facilitate communication between them."
Patients may confide in you
At other times, the claimant may confide information to Frontera that the physician is unaware of, she notes. Frontera remembers one claimant with uncontrolled hypertension who, according to her file, was receiving multiple prescriptions to treat her hypertension, yet still not able to bring her blood pressure down to an acceptable level.
"I asked her to be honest with me and she confided that she hadn’t had any of the prescriptions filled, because she couldn’t afford them. She hadn’t told her physician because she was embarrassed."
Frontera asked the claimant for permission to discuss the matter with her physician. "I asked her physician whether it was possible for him to give her free samples. He did, and her blood pressure finally was controlled. I don’t think the nurse should come between the physician and the patient but it is appropriate to help the physician and the patient develop an open dialogue."
At other times, the claimant may have an adverse reaction to a medication the physician has prescribed that the physician is unaware of, notes Frontera. "I’ll call the physician and say that the claimant is complaining that the medication is causing nausea, and ask what alternatives are available. In addition, I do encourage claimants to contact their physicians directly to discuss their medical needs and often help them formulate questions to ask."
It also helps if you can lift part of the administrative burden of the claim off the physician’s shoulders. "I always tell the physician that there’s no need to fill out a form or send me a letter about the claimant now that we’ve talked. I offer to do the necessary documentation."
In addition, Frontera finds that claimants don’t always communicate to their physicians what their job involves. "Sometimes, the physician hasn’t released the claimant back to work simply because he doesn’t know what the job requires. I tell the doctor, or the occupational consultant tells the doctor, what the job requires. Then we [say], Don’t tell me what the patient can’t do, tell me what he can do.’ If the patient is unable to return to work, I ask the physician what test results or positive exam findings he has that indicate this patient is incapable of doing his job."
• Bring out the big guns. If a treating physician is particularly uncooperative, Frontera asks one of the physician advisors she works with at CIGNA to make a call to the treating physician. "That physician-to-physician call is definitely the hardball’ approach. It also often makes the difference with a claim. Generally by the end of these calls we have a better understanding of the claimant’s medical conditions, the physician’s treatment plan and the prognosis for return to work."
The case manager remains the person who keeps all the pieces of the claim together from the time CIGNA receives it until the claim is either denied or closed. "We have [a procedure] that case staffing and then the occupational
consultant, or the medical consultant, whoever is working with the claim, reports back to me verbally with updates as necessary," says Stagliano.
"When I first started at CIGNA, we didn’t use the team approach. I’ve witnessed how much smoother the entire claims process is now. The occupational and medical consultants have expertise that I don’t have. And I have an understanding of the benefits that they don’t have, I definitely think the team approach benefits the claimant and the employer."
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