Understanding the Injury Management Process: A 2022 Guide for TPAs and Self-Insured Companies
When an employee gets sick or injured on the job, a medical case manager is responsible for facilitating necessary treatment, helping both the employee and employer navigate the rules of NY’s Medical Treatment Guidelines and expediting a safe return to work.
But what about all the forms that need to be filled out correctly and completed within proper timelines? Who determines when hearings are scheduled and what the employer representation should be? Who works with adjusters on more complicated files to ensure that reserves and treatment is reasonable and within the Medical Treatment Guidelines?
This process—navigating the entirety of a worker’s comp injury, from claim to settlement—is injury management. Where medical case management is led by registered nurses and focuses solely on getting an employee back to work, injury management is managed by claims experts and involves the behind-the-scenes administration and coordination needed to successfully resolve the claim.
Injury management is a boutique service that, when done well, works in parallel with medical case management. In this article, we outline the unique role injury managers play, the shifting guidelines our injury managers are watching in 2022 and the most commonly asked questions we receive about injury management from TPAs and self-insured companies directly from employers.
The Role of an Injury Manager
Injury managers oversee the entire lifecycle of a worker's compensation injury, from filing to closure, on behalf of the employer. Our work begins with determining whether a claim needs to be filed for an injury—does it fall under worker’s compensation?—and ends with the last medical bill being paid or a settlement being agreed to. While a claim can jump from claims adjuster to claims adjuster at an insurance carrier, an injury manager acts as the key point person for an employer throughout the duration of the claim, which often takes years.
Injury managers have three driving goals:
Help employers navigate all the moving parts of a claim efficiently
Help employers save money
Free up Leave of Absence Coordinators and HR teams to work on more pertinent issues, especially in a post-COVID world
We often talk about medical case managers as the air traffic controllers of workers’ comp; injury managers take this metaphor to a new level. Acting as the intermediary between employers, carrier representatives and injured workers, injury managers are responsible for knowing the intricacies and nuances of the full claims process—from forms to deadlines to what to watch out for—while staying on top of changing rules, regulations, policies and procedures.
Here’s a snapshot of how injury managers work with employers, injured workers, adjusters and providers.
Employers
Injury managers work on behalf of employers. They are responsible, first and foremost, for helping employers determine when a claim should be filed and if a claim is considered workers’ compensation. When it is, injury managers ensure all forms are filled out correctly and submitted within the correct time frame, assist in wage calculations, determine when hearings are scheduled and what forms or employer representatives are required and to keep employers regularly updated on the injured worker’s treatment, independent medical exams, reserves and more.
Injured Workers
Injury managers also act as a key point person for injured workers, explaining the often complicated laws of workers’ compensation including their indemnity payments, how to navigate the independent medical exam process, how their pay is calculated, what to do when a hearing is scheduled and more. This role is critical for employers who want to support their injured workers but do not have claims management experts on staff.
Adjusters and Providers
In an effort to get the claim settled or closed efficiently, injury managers also liaise regularly with adjusters and providers on behalf of the employer. Injury managers work with doctors to get medical records submitted when injured workers’ pay is suspended due to lack of medical evidence. When doctors are unresponsive or a request for treatment has not been responded to, injury managers are the ones to follow-up. Injury managers also work closely with adjusters on more complicated files to ensure that reserves and treatment are reasonable and fall within the Medical Treatment Guidelines.
Injury Management: What to Watch for in 2022
It’s crucial that injury managers stay on top of important shifts in the claims process. Here are three changes to jurisdictional rules and regulations, the drug formularies and return-to-work industry standards that our injury managers are keeping an eye on this year:
Possible OSHA Changes Due to Continued Pandemic Needs
As the CDC continues to update its guidelines, we may see changes in vaccine and booster requirements, mask mandates and quarantine timeline changes. Companies need to continue to closely monitor the CDC and OSHA to stay up-to-date on guidelines that impact employee and workplace safety.
The NYS WCB releasing OnBoard and PARs
The NYS WCB is building a new, web-based claims system called OnBoard. The project has been underway since September of 2019 and the rollout has been delayed due to the pandemic. Most recently, the Claims Electronic Data Interface R3.1 implementation took place on January 24, 2022. EDI is a national standard for partners to electronically submit claims data. The Medical Portal and Prior Authorization Request (PAR) pieces of OnBoard currently do not have release dates. More information on the EDI release can be found here.Form Updates
At the end of 2021, several New York Medical Treatment Guideline forms were updated including the DB-120.1, OC-400 and EC4.3. Once OnBoard is released, we also anticipate a change to the HP-1.0 form (decision on unpaid bills). When the new claims system is live, all forms will be available electronically for submission and the WCB may institute additional form changes at that time.
Injury Management FAQ: TPA and Self-Insured Edition
Here are seven of the most common questions we receive about the injury management process from our TPA and self-insured partners:
Isn’t the claims adjuster doing this work?
The claims adjuster monitors the medical treatment and bills and makes decisions on treatment requests and financial resources for the claim. The Injury manager is an advocate for the employer and manages the full claims process, ensuring every aspect of the claim is progressing towards closure. The injury manager also acts as a liaison between adjusters and employers, often answering critical and often nuanced injury management questions on the employer’s behalf (like, “is light duty available?” and “do you have a shutdown period?”)Can injury managers reduce the reserves?
No, only an adjuster can reduce the reserves. However, an injury manager can suggest that reserves are too high after reviewing a file. By reaching out to the adjuster to ask that they review the file based on IME results, doctors notes, etc. reserves can oftentimes be reduced.
Why is the injured worker still out of work?
The injured worker can be out of work for a number of reasons. The two most common are that the injured worker’s doctor has recommended the employee remain out of work or the doctor has cleared the employee for full-time or light duty work with restrictions but the employer cannot accommodate the restrictions.
Why is the injured worker getting paid?
If it is determined by the injured worker's treating doctor that they cannot return to work then the injured worker will continue to be paid. Payments will stop if there has been no medical evidence that the employee needs to remain out of work. Payments can also increase or decrease based on the treating provider's determination of the disability status.
Why do you need the C-11 and C-240 completed?
Both forms are crucial for handling a claim. A C-240 is used to determine the average weekly wage that an employee was making in the prior 52 weeks before the injury. This determines the injured worker’s pay while they are out of work for their injury. The C-11 provides the work status and/or change in work status of the injured employee. It notes the date that the employee started missing work due to the injury and is amended throughout the claim if they return to work or goes out of work for surgery or pain due to the injury.
I am questioning the injury—do I need to file a claim?
Yes the claim should be filed either way. If you are questioning the injury, it’s important to note that so the injury manager can alert the claims adjuster when filing the claim. It may seem counterintuitive, but you need to have a claim in order to deny the claim (see here for more).
What is the process of claim filing?
First complete a First Report of Injury (FROI) and send it to the injury manager so they can file the claim with the appropriate carrier. Forms C-11 and C-240 will be requested when the injured worker is out of work. Once the claim is filed, the injury manager will obtain and share the claim number with the injured worker and employer. Any medical bills that come in will then be associated with that claim number.
Here at Viscardi, we’re known for our progressive, human-to-humancase management work and our nearly twenty year expertise in the industry. Now, we’re excited to offer Injury Management services to TPAs and self-insured companies and offer a team of claims experts and medical professionals working together under one (socially-distanced) roof. If you have questions about the injury management process or are looking for a partner to help manage your claims, send us an email here.