A. Skillful case management in the field of workers’ compensation demands specialized knowledge, skills, and understanding of pertinent terms, practices, and parameters not usually taught in health care settings.

B. It is essential for the case manager practicing in the workers’ compensation field of case management to be familiar with the terms used throughout the industry and how to apply them in practice.

C. Review of the history of workers’ compensation programs in US business leads to an understanding of today’s health care delivery and workers’ compensation systems.

D. The industrial revolution in America that began the transformation of the workforce from agrarian to industrial in the late 19th and early 20th centuries spawned the workers’ compensation system that has taken us into the 21st century. In fact, case management began in the workers’ compensation arena.

E. As the workplace became larger and more mechanized, the risk to workers increased. Social reformers recognized the need for legislated standards to protect individual workers and the community as a whole.

F. The first laws passed in the various states merely replaced common law with enacted laws, but the burden remained on the injured worker to prove employer responsibility.

G. In 1911, the first state workers’ compensation laws were enacted that established a no-fault system to deal with work-related injuries.

H. Today, all 50 states and several US territories have workers’ compensation laws.

I. Federal legislation also has been enacted to cover federal programs for workers’ compensation.

J. It is important for case managers directly or indirectly caring for injured workers to be familiar with workers’ compensation state and federal laws or how to access such information when needed. Often, case managers in acute or other care settings care for injured workers while collaborating with the workers’ compensation claims adjuster or case manager.

A. Disability—Is a limitation in an activity and/or participation restriction in an individual with a health condition, disorder, injury, or disease.

B. First report of injury (FROI)—This is a formal document completed by the employer—a report of a work-related injury or condition—that begins the process of a workers’ compensation claim. The report is filed with the appropriate state jurisdiction and sent to the workers’ compensation carrier or third-party administrator (claim handlers for self-insured employers). Workers’ compensation systems allow injured workers or their designee to file a report of injury directly with the relevant state or federal workers’ compensation board or industrial commission.

C. Functional capacity examination (FCE)—A systematic, objective process of assessing an individual’s physical capacities and functional ability to execute tasks (e.g., sedentary, light, medium tasks). The FCE matches human performance levels to the demands of a specific job, work activity, or occupation. The FCE is often used in determining a person’s potential for job placement, accommodation, and/or return to work after an injury. A comprehensive FCE also determines the individual’s level of effort expended during testing, which can be a critical piece of information to have documented.

D. Impairment—Is a significant deviation, loss, or loss of use of any body structure or body function in an individual with a health condition, disorder, injury, or disease.

E. Impairment rating—The basis for determining the medical outcome of a workers’ compensation claim. Many states require an impairment rating to be based on the findings of a licensed physician using an impairment rating system such as the Guides to the Evaluation of Permanent Impairment, sixth edition, published by the American Medical Association (AMA).

F. Indemnity payments—Monies paid as wage replacement when the injured worker is determined to be medically unfit to work. Indemnity payments are based on the worker’s usual wage, factored by a formula set by the state that has jurisdiction for the claim.

G. Maximum medical improvement (MMI) and maximum medical recovery (MMR)—Terms used to indicate that the injured worker has recovered from injuries to a level at which a physician states that further treatment will not substantively change the medical outcome.

H. Permanent partial disability—The designation used to indicate that there is a presumptive or actual decrease in wage-earning capacity due to injury. A benefit is paid according to the severity of impairment in a formula derived by the state. Most states have scheduled injuries (benefit paid by a formula based on loss of, or loss of the use of, specific body members) and nonscheduled injuries (a benefit is based on the percentage of impairment in a formula computed by the state).

I. Permanent total disability—This evaluation is based on a medical assertion that the injured worker is precluded by the extent of his or her disability from gainful employment. Each state has guidelines on which this designation and subsequent benefits are paid.

J. Reasonable accommodation—Any change in the work environment or in the way a job is performed that enables a person with a disability to enjoy equal employment opportunities. There are three categories of reasonable accommodations—changes to a job application process, changes to the work environment or to the way a job is usually done, and changes that enable an employee with a disability to enjoy equal benefits and privileges of employment (such as access to training).

K. Reserves—The sum of money the insurance company or self-insured funds set aside to pay all costs associated with a claim.

L. Risk—In the workers’ compensation field, risk refers to the extent of loss an organization is able to tolerate or feels comfortable tolerating. The organization usually plans for and manages what is probable or expected and applies a target against which it compares actual occurrences and experiences. The target is determined based on national benchmarks and state or federal laws and regulations.

M. Temporary partial disability—Status in which impairment prevents an injured worker from returning to his or her usual job, but the worker can be employed in some capacity. A benefit is paid when the restrictions to work activity result in a decrease of usual wages.

N. Temporary total disability—Status in which indemnity is paid when an injured worker is unable to work in any capacity while treatment continues, with the expectation of recovery and return to employment.
In most states, the injured receives benefits for the entire time he or she is medically deemed to be unable to work.

O. Vocational rehabilitation—Cost-effective case management services provided by a skilled professional (preferably certified as a vocational rehabilitation professional or counselor) who is knowledgeable about the implications of medical status, functional ability, and vocational services necessary to facilitate an injured workers’ expedient return to gainful employment.

A. The Case Management Society of America (CMSA) describes in its standards of practice for case management (CMSA, 2010) that case management practice extends across all health care settings and providers of various professional disciplines. This without a doubt applies to the practice of workers’ compensation case management whether in health insurance plans or employer settings.

B. Workers’ compensation case managers (as all case managers) should use the CMSA standards as a guide for the implementation of their roles. All standards are relevant to workers’ compensation including and perhaps especially the legal and ethical expectations.

C. It is important for case managers in the workers’ compensation care settings to be aware of the CMSA standards of practice. When needed, they may inform their employers and other professionals they collaborate with when dealing with a client with a work-related injury or occupational illness about the availability of these standards if appropriate and their value.

D. This chapter introduces case managers to the basic concepts of workers’ compensation practice, role of the case manager in such setting, and explains how collaboration may occur between case managers in the workers’ compensation and other care settings.

A. Provide injured workers (or those suffering from an occupational illness) prompt medical care and wage replacement.

B. Establish a single, primary remedy for workplace injuries to decrease the legal costs and relieve the judicial system of heavy caseloads of personal injury cases.

C. Relieve both the public and private sectors from demands on financial, medical, and rehabilitative services.

D. Provide a system for the delivery of workers’ compensation benefits, resources, and services.

A. The injuries or occupational illnesses covered under the relevant workers’ compensation statute must “arise out of and in the course of employment.”

B. Medical costs may represent 60% or a higher portion of workers’ compensation expenses. Contributing factors to such costs are as follows:

C. Workers’ compensation program costs are born by the employers. Whether they “self-fund” or “self-insure” their workers’ compensation programs, or make this benefit available through purchased insurance policies, employers must meet state requirements for these types of programs/insurance.

D. The cost of workers’ compensation insurance and all costs associated with workplace injuries (or wellness and prevention of injuries) are reflected in the price of goods and services sold by the employer.

E. Besides the direct cost of buying insurance premiums, workers’ compensation medical and rehabilitative care, and indemnity payments, there are other indirect costs associated with these programs that are included in the total cost of occupational disability:

F. The cost of buying workers’ compensation insurance is based on a formula of previous claims, types of workers insured (e.g., clerical personnel have less risk of injury than do truck drivers), and an element calculated by the state based on annual costs (US Chamber of Commerce, 2015). The only factor that can be effectively modified by the employer is the cost associated with the number and severity of workplace injuries.

G. Workers’ compensation insurance carriers and self-insured employers have a stake in decreasing costs of claims submitted to them. A competitive marketplace demands that companies sell their products at the lowest possible price; this provides the foundation for managing the cost of risk, and, ultimately, the cost of workers’ compensation claims and experience.

H. Many strategies are employed in keeping claims costs low, including loss control, risk or absent management programs, as well as safety and health programs plus managed care arrangements (Box 24-1).

A. Medical management processes have been involved in the periphery of workers’ compensation programs for a number of years, both medically and vocationally.

B. Economic changes and escalating medical costs have placed a larger burden on employers required to provide workers’ compensation coverage for their employees.

C. Case management strategies, as a component of health insurance and managed care arrangements, can be used as tools to lower workers’ compensation and medical costs, improve communication, promote best medical and claim outcomes, and maintain a stable workforce.

D. A workers’ compensation claim can be a complicated, often protracted process in which case managers can become involved at any time.

E. Workers’ compensation laws demand the case management process be adapted to work within the workers’ compensation and occupational health and safety structure.

A. Case managers working in the workers’ compensation field encounter a greater number of stakeholders than in other areas of case management practice (see Box 24-2).

B. Adapting usual case management techniques and practices to the workers’ compensation field requires the practitioner to recognize the responsibilities of the various people and organizations with a role in mediating a work-related injury claim (Box 24-3).

C. Due to the large amount of stakeholders, the role of case management is more challenging yet also even more critical.

A. Laws governing workers’ compensation administration are enacted by each state and territorial legislature and administered by state agencies.

B. The U.S. Congress regulates areas of workers’ compensation whose programs are deemed under national commerce. These programs with their own subsets are:

C. Laws are written and amended frequently. Because case managers must comply with the laws in order to practice legally and ethically, a source for learning about them is essential. Comprehensive compendia of state and federal laws can be found in:

D. Each state has its own workers’ compensation laws, which vary from one state to another; however, the main aspects of workers’ compensation case management tend to be similar.

E. The specific workers’ compensation laws that are governed federally and cover individuals in certain industries such as railroad workers, longshoremen, and federal employees may be specific to vocational benefits and entitlements of spouses or dependents, especially when the situation involves death.

F. The workers’ compensation laws function as “no-fault” laws and protect the employer from civil lawsuits. However, third-party lawsuits can evolve whether due to aspects such as mechanical abnormalities or malfunction that caused the injury. This adds another line of legal contacts.

G. Workers’ compensation laws dealing with claim issues may appear to have only a peripheral impact on medical management. However, knowledge of laws affecting the medical system has a direct effect on the case manager’s ability to accomplish case management goals and objectives. Some states restrict the contacts with the injured worker up to allowing the injured workers’ attorneys to attend provider appointments with the case manager.

H. Workers’ compensation case managers have a responsibility to be familiar with applicable laws but must exercise caution to avoid the appearance of giving legal advice or directing care to key stakeholders, especially injured workers, health care providers, employers, and adjusters, among others.

I. Arguably, the most challenging laws for workers’ compensation medical managers are those that dictate the selection and use of health care providers. States may mandate the manner in which providers or medical services can be chosen.

J. State regulations pertaining to the use of health care services by injured workers often reflect efforts to contain medical costs. MCOs for workers’ compensation health care providers are allowed or required in a few states.

K. Mandated managed care requirements are available from the state workers’ compensation administrative agency (see listing of Web sites at the end of this book for relevant state and federal links).

L. Guidelines for case managers working for or with an MCO vary by state.

M. States (such as CA) mandate the use of evidence-based medical (EBM) treatment protocols (or in FL, that providers be knowledgeable about relevant EBM guidelines) to direct the medical care of injured workers by their health care providers. The use of EBM tools reduces unnecessary medical care, facilitates positive medical outcomes, and ultimately saves costs.

N. Sources of EBM protocols for workers’ compensation medical care and required in most state guidelines include:

O. Almost all states and territories set up second injury funds for injured workers. These assist the injured worker and provide a financial offset for the employer. Conditions covered may include:

P. Vocational rehabilitation as provided by workers’ compensation regulations is sometimes coordinated concurrently with medical management.

A. The entire range of case management practices can be applied in a workers’ compensation industry or work setting. The skills, knowledge, and competencies described in other chapters of this book are also critical for case managers in the workers’ compensation specialty case management practice.

B. There are customary requirements for employment as a workers’ compensation case manager.

C. The settings in which a case manager might practice these processes are varied.

D. The organization or facility paying for case management services often determines the scope and duration of the requested case management service(s).

E. The case management process as described in Chapter 12 and by many other authors can be applied to the most frequently encountered workers’ compensation claims. Items F through M below highlight important aspects of the workers’ compensation case management process.

F. Case finding and client targeting

G. Evaluating and assessing