The Total PackageThe Total Package

Dawn Vincent RN CRRN LNCC MSCCDawn Vincent RN CRRN LNCC MSCC

What are the similarities and What are the similarities and differences?differences? WC Case ManagersWC Case Managers Assimilate information, Assimilate information,

formulate opinions and formulate opinions and present in a concise, present in a concise, orderly fashion.orderly fashion.

Interpret medical Interpret medical records, MRI reports, records, MRI reports, etc. and relay to the etc. and relay to the adjuster, attorney, etc in adjuster, attorney, etc in easy to understand easy to understand language.language.

WC CM’s are master WC CM’s are master coordinators. They coordinators. They coordinate medical coordinate medical appt’s with work appt’s with work schedules, PT schedules, PT schedulesschedules

Legal Nurse Legal Nurse ConsultantsConsultants

Assimilate information, Assimilate information, formulate opinions and formulate opinions and present in a concise, present in a concise, orderly fashion.orderly fashion.

Interpret medical Interpret medical records, MRI reports, records, MRI reports, etc. and relay to the etc. and relay to the adjuster, attorney, etc in adjuster, attorney, etc in easy to understand easy to understand language.language.

Legal Nurse Consultants Legal Nurse Consultants are master coordinators . are master coordinators . They assist in They assist in coordinating expert coordinating expert witnesses, depositions, witnesses, depositions,

Types of job settings:Types of job settings:

WC CASE WC CASE MANAGERMANAGER

WC Insurance WC Insurance CompanyCompany

Case Management Case Management Co.Co.

Attorney’s officesAttorney’s offices Government Government

OfficesOffices Independent CM’sIndependent CM’s HospitalsHospitals Large industry Large industry

settingssettings

LEGAL NURSE LEGAL NURSE CONSULTANTCONSULTANT

Attorney’s officesAttorney’s offices Insurance Insurance

CompaniesCompanies WC Insurance WC Insurance

CompaniesCompanies Independent LNC’sIndependent LNC’s

Find a niche for your special Find a niche for your special expertise and market that….expertise and market that….Examples of these could be:Examples of these could be: High Risk Obstetrics Claims-believe it or not, can be High Risk Obstetrics Claims-believe it or not, can be

work related-injured while working, becomes work related-injured while working, becomes related, related,

Cardiology ClaimsCardiology Claims Traumatic Brain InjuryTraumatic Brain Injury Spinal Cord InjurySpinal Cord Injury Catastrophic Claims in GeneralCatastrophic Claims in General ““Major Claims” (many insurance companies have Major Claims” (many insurance companies have

Major Claims units- for their cat claims, over a Major Claims units- for their cat claims, over a certain $$ amount or a certain type of injury triggers certain $$ amount or a certain type of injury triggers it to go to this unit)it to go to this unit)

Number crunching-you can assist claims adjusters Number crunching-you can assist claims adjusters with setting reserves by figuring what the injury is with setting reserves by figuring what the injury is going to cost them for the life of the filegoing to cost them for the life of the file

How being a WC CM + LNC = How being a WC CM + LNC = Positive work experience for youPositive work experience for you

Combining your experience as a WC Combining your experience as a WC CM and a LNC you bring to the table a CM and a LNC you bring to the table a bevy of skills that many companies bevy of skills that many companies would have to hire at least 2 people towould have to hire at least 2 people to fulfill the job set for. You have it in 1 fulfill the job set for. You have it in 1 person……..YOU! person……..YOU!

Sample Case:Sample Case:

Let’s look at an example of how Let’s look at an example of how a WC CM that is also a LNC a WC CM that is also a LNC impacted a file that had been impacted a file that had been case managed for case managed for 15 years15 years by a by a vendor case manager with no vendor case manager with no end in site. Cost of vendor case end in site. Cost of vendor case management: $32,000/yr for management: $32,000/yr for total of $480,000.000 over 15 total of $480,000.000 over 15 years.years.

Sample case demographics:Sample case demographics:

42 year old male, 27 at time of injury. 42 year old male, 27 at time of injury. Hit in the right side of head with a Hit in the right side of head with a board that dropped from a height of board that dropped from a height of approximately 5’, clipping the right approximately 5’, clipping the right side of his head. It was a ¼” sheet side of his head. It was a ¼” sheet of plywood cut into a 2’ x2’ section of plywood cut into a 2’ x2’ section (to cover a window). It was a (to cover a window). It was a glancing blow, there was no LOC, he glancing blow, there was no LOC, he did not fall to the ground, slight 1” did not fall to the ground, slight 1” laceration to the scalp that did not laceration to the scalp that did not require stitches. require stitches.

Demographics continuedDemographics continued

EE had a hx of numerous prior EE had a hx of numerous prior psychiatric admissions for psychiatric admissions for violent behavior and a hx of violent behavior and a hx of drug abuse x 10 years. He had drug abuse x 10 years. He had 2 minor children and was 2 minor children and was married at the time. He had 4 married at the time. He had 4 prior WC injuries. IW insisted prior WC injuries. IW insisted on going to the ER for this minor on going to the ER for this minor injury.injury.

ER VISITER VISIT

Initial ER visit 1” laceration, bleeding controlled with Initial ER visit 1” laceration, bleeding controlled with pressure, no sutures. AOx3. Discharged to home with pressure, no sutures. AOx3. Discharged to home with instructions to use ice to head if swelling noted, tylenol instructions to use ice to head if swelling noted, tylenol for pain.for pain.

The next day IW and wife were back at ER, she was The next day IW and wife were back at ER, she was complaining he was having violent outbursts since complaining he was having violent outbursts since injury (un-witnessed) & that this was not like him (no injury (un-witnessed) & that this was not like him (no one in WC or medical field was aware at this time of one in WC or medical field was aware at this time of his previous admissions to psych), this continued on his previous admissions to psych), this continued on for several days with frequent trips to ER and for several days with frequent trips to ER and diagnosis was changed from contusion to TBI. This diagnosis was changed from contusion to TBI. This was the beginning of IW building a WC case, and of a was the beginning of IW building a WC case, and of a IW misguided by the legal system, the medical system IW misguided by the legal system, the medical system and eventually his own family.and eventually his own family.

Rehabilitation or life in prison?Rehabilitation or life in prison?

After thousands of dollars in After thousands of dollars in tests were run at the expense of tests were run at the expense of WC, (MRI’s, CT’s EEG’s, WC, (MRI’s, CT’s EEG’s, EKG’s, etc., etc) the doctor’s still EKG’s, etc., etc) the doctor’s still found no reason for IW’s violent found no reason for IW’s violent outbursts. It was decided to try outbursts. It was decided to try inpatient rehabilitation to see if inpatient rehabilitation to see if any of his behavior issues could any of his behavior issues could be managed in that setting. be managed in that setting.

Cont.Cont.

After 14 months of inpatient rehab, IW After 14 months of inpatient rehab, IW was scheduled to be discharged to was scheduled to be discharged to return to work full duty and his attorney return to work full duty and his attorney had him transferred to another rehab had him transferred to another rehab facility in another state that specialized facility in another state that specialized in TBI. At this time, IW was deemed in TBI. At this time, IW was deemed recovered and able to RTW FD and recovered and able to RTW FD and had no continued diagnosis that had no continued diagnosis that supported this transfer. He had a supported this transfer. He had a simple scalp contusion and laceration simple scalp contusion and laceration that had been upgraded to a TBIthat had been upgraded to a TBI

because because his wife said his wife said he was he was having un-witnessed violent having un-witnessed violent outbursts.outbursts.

15 years of cost leakage for work 15 years of cost leakage for work comp company = need for comp company = need for LNCC/WC CMLNCC/WC CM The IW spent the next 15 years being The IW spent the next 15 years being

shuffled from one TBI facility to shuffled from one TBI facility to another till 2003 when WC+LNCC CM another till 2003 when WC+LNCC CM received file to case manage.received file to case manage.

IW had Lost jobIW had Lost job Social SecuritySocial Security Became interdicted & step-mom took Became interdicted & step-mom took

over all aspects of his life,over all aspects of his life, Wife divorced himWife divorced him Children grew apart from himChildren grew apart from him

Cont.Cont.

Lost 2 homes he ownedLost 2 homes he owned He had also claimed that the blow to He had also claimed that the blow to

his head injured his neck and back and his head injured his neck and back and had been receiving chiropractic care x had been receiving chiropractic care x 15 years, physiatrist care x 15 years, 15 years, physiatrist care x 15 years, neurology x 15 years, pharmacology x neurology x 15 years, pharmacology x 15 years, psychiatric care x 15 years, 15 years, psychiatric care x 15 years, he had joined an elite health club under he had joined an elite health club under WC’s dime for the past 5 years and WC’s dime for the past 5 years and was getting his BP medication, ED and was getting his BP medication, ED and other unrelated medications paid for other unrelated medications paid for under WC.under WC.

Turn the case aroundTurn the case around

Injury occurred in 1988, LNCC/WC Injury occurred in 1988, LNCC/WC CM took over case in 2003 from CM took over case in 2003 from vendor CM’svendor CM’s

Attended the monthly staffing Attended the monthly staffing meetings & made presence known to meetings & made presence known to current facility-questioned most of current facility-questioned most of their modalities-they were in a status their modalities-they were in a status quo mode-getting paid a lot for doing quo mode-getting paid a lot for doing a little and adding a lot of fluff.a little and adding a lot of fluff.

Made sure it was understood Made sure it was understood EVERYTHING had to be approved EVERYTHING had to be approved through CM-nothing could just bethrough CM-nothing could just be

Be tough..Be tough..

ordered and done, had to be ordered and done, had to be approved first, if it wasn’t approved first, if it wasn’t medically necessary and related medically necessary and related to original injury, it didn’t get to original injury, it didn’t get done.done.

Get Active, Move that FileGet Active, Move that File

Start finding proper specialists for IME’sStart finding proper specialists for IME’s Get Voc involved to facilitate RTW – even Get Voc involved to facilitate RTW – even

after 15 years-this facility was using their after 15 years-this facility was using their own vocational rehabilitation people-own vocational rehabilitation people-LNCC/WC CM didn’t feel they were pro-LNCC/WC CM didn’t feel they were pro-active and aggressive enough, very active and aggressive enough, very lacsidaisical in their approach to RTW, took lacsidaisical in their approach to RTW, took months to help IW complete job months to help IW complete job application. LNCC/WC CM got State Voc application. LNCC/WC CM got State Voc involved to assist in RTW, job coaching, involved to assist in RTW, job coaching, etc.etc.

Always be thinkingAlways be thinking

Get Social Worker started on Get Social Worker started on helping finding proper home helping finding proper home placement-IW’s will need a placement-IW’s will need a place to live if family is not an place to live if family is not an option, in many places Section 8 option, in many places Section 8 has a 1-2 year waiting list so this has a 1-2 year waiting list so this is something to think about is something to think about immediately, SW’s aren’t!immediately, SW’s aren’t!

Document, Document, DocumentDocument, Document, Document While implementing all these changes, While implementing all these changes,

make sure you are documenting very make sure you are documenting very well. You are rocking the boat! This is well. You are rocking the boat! This is where the cross between LNC and where the cross between LNC and WC blend so well, the WC CM knows WC blend so well, the WC CM knows exactly what is needed for the IW and exactly what is needed for the IW and the file and the LNC part of her/him the file and the LNC part of her/him knows what is within the legal realm knows what is within the legal realm and within work comp statutes, etc. and within work comp statutes, etc. This is the total package.This is the total package.

Neuropsych IME concluded that IW never had a Neuropsych IME concluded that IW never had a TBI, at most, he had a concussion-should have TBI, at most, he had a concussion-should have RTW in 1988, however he now has a “Learned RTW in 1988, however he now has a “Learned Brain Injury” from being in TBI facilities for yearsBrain Injury” from being in TBI facilities for years

Worked with IW’s treating PM&R over a 2 yr Worked with IW’s treating PM&R over a 2 yr time span and was able to get him to say that time span and was able to get him to say that back and neck NOT related to original injury back and neck NOT related to original injury after he read original neuropsych eval of 1993 after he read original neuropsych eval of 1993 and then IME of 2005 and was able to get him and then IME of 2005 and was able to get him to say he may need up to 6 PT visits per year, 2 to say he may need up to 6 PT visits per year, 2 PM&R visits per year for medication PM&R visits per year for medication management & weaning x next 3 years; that in management & weaning x next 3 years; that in turn did away with chiropractic treatment, health turn did away with chiropractic treatment, health club membership; club membership;

Back to the Case…..Back to the Case…..

Knowing which key to use to Knowing which key to use to unlock the mystery….unlock the mystery…. The neuropsychological evaluationThe neuropsychological evaluation This held the magic key for this file for This held the magic key for this file for

almost every aspect-almost every aspect- PM&R-based on the findings-convinced PM&R-based on the findings-convinced

this MD to reverse his diagnosis & tx plan this MD to reverse his diagnosis & tx plan & WC will not owe for this IW’s neck and & WC will not owe for this IW’s neck and back for the rest of his lifeback for the rest of his life

Psych-based on the findings-irrefutable Psych-based on the findings-irrefutable findings that proved that IW had pre-findings that proved that IW had pre-existing psych issues and violent existing psych issues and violent tendencies that were NOT produced by the tendencies that were NOT produced by the mild blow to the head. WC will not mild blow to the head. WC will not continue to owe psych for the rest of IW’s continue to owe psych for the rest of IW’s life.life.

Cont.Cont.

Return to WorkReturn to Work It was determined IW was able It was determined IW was able

to RTW with assistance from to RTW with assistance from voc and job coaching-he voc and job coaching-he eventually RTW at 2 jobs!eventually RTW at 2 jobs!

The Process…..The Process….. SocioEconomicSocioEconomic IW wanted his life back-a home/appt, a IW wanted his life back-a home/appt, a

driver’s license, a car, his right to make driver’s license, a car, his right to make decisions againdecisions again

It was determined that the It was determined that the neuropsychologist would be in charge of neuropsychologist would be in charge of determining a plan set on a 6 month timeline determining a plan set on a 6 month timeline with specific goals to be met for IW to with specific goals to be met for IW to achieve in order to “get his life back” and be achieve in order to “get his life back” and be discharged from the inpatient TBI setting. discharged from the inpatient TBI setting.

Baby StepsBaby Steps Get a job and keep it for at least 3 Get a job and keep it for at least 3

monthsmonths Proving he could maneuver the city on Proving he could maneuver the city on

public transportation without assistance public transportation without assistance from staff or case management for those from staff or case management for those 3 months3 months

Then, he would be allowed to get a Then, he would be allowed to get a drivers licensedrivers license

After obtaining a driver’s license, he After obtaining a driver’s license, he would be allowed to drive his parent’s would be allowed to drive his parent’s spare truck after obtaining proper spare truck after obtaining proper insurance and he would be allowed to insurance and he would be allowed to park it on hospital property. He would be park it on hospital property. He would be allowed no tickets or accidents.allowed no tickets or accidents.

Cont.Cont. After driving for 2 months and After driving for 2 months and

working now for 5 months, he would working now for 5 months, he would be allowed to look for a place to live be allowed to look for a place to live & it would have to meet with & it would have to meet with parents approval, hospital staff parents approval, hospital staff approval & CM approvalapproval & CM approval

After all these steps were After all these steps were accomplished, and he lived on his accomplished, and he lived on his own for a few months, then own for a few months, then reversing his interdiction would be reversing his interdiction would be looked at.looked at.

Benefits for IWBenefits for IW

Regains independenceRegains independence Gives IW a new lease on life, a Gives IW a new lease on life, a

new startnew start Able to feel productive, Able to feel productive,

worthwhile, he liked knowing worthwhile, he liked knowing there really wasn’t something there really wasn’t something wrong with him after he got over wrong with him after he got over his initial anger of loosing 15 his initial anger of loosing 15 years of his life.years of his life.

Benefits to Insurance Benefits to Insurance CompanyCompany Cost Savings:Cost Savings: Initial cost savings were by using Initial cost savings were by using

internal CM vs Vendor CM-$30.00/hr vs internal CM vs Vendor CM-$30.00/hr vs $125.00/hr$125.00/hr

Negotiated monthly price for inpatient Negotiated monthly price for inpatient rehab. Current mo/pr was $20,150.00. rehab. Current mo/pr was $20,150.00. Neg to $15000. Cost savings of Neg to $15000. Cost savings of $61,200./yr$61,200./yr

Utilized PPO providers for transportationUtilized PPO providers for transportation Referred IW to all community liaison Referred IW to all community liaison

resources for assistance.resources for assistance.

Cont.Cont. Purchased Health Club Purchased Health Club

Membership for $219.14/yr x 1 yr to Membership for $219.14/yr x 1 yr to cut costs of aqua therapy 3 x wk @ cut costs of aqua therapy 3 x wk @ $125.00/visit cost savings $125.00/visit cost savings $375.00/wk x 6 wks = $2250.00$375.00/wk x 6 wks = $2250.00

Got PM&R to reduce chiro or PT to Got PM&R to reduce chiro or PT to 6 visits per yr. Iw had een treating 6 visits per yr. Iw had een treating with chiro typically 3 times/wk x 15 with chiro typically 3 times/wk x 15 yrs. Cost savings of $100./visit x 1 yrs. Cost savings of $100./visit x 1 time avg per wk x 52 wks = time avg per wk x 52 wks = $5200.00$5200.00

Winding down….Winding down…. Had IW evaluated by urologist for Had IW evaluated by urologist for

impotency issues and causal impotency issues and causal relationship. Found not causally relationship. Found not causally related to injury but to tobacco use, related to injury but to tobacco use, thus we were able to discontinue thus we were able to discontinue paying for Levitra, Viagra and Cialus, paying for Levitra, Viagra and Cialus, Cost savings of cost of medications: Cost savings of cost of medications: Viagra $268.97 x 30 tablets, Cialis Viagra $268.97 x 30 tablets, Cialis $269397 x 30, levitra $253.97 x 30. $269397 x 30, levitra $253.97 x 30. Yearly cost saving of ONE of these Yearly cost saving of ONE of these medications is $3239.64 medications is $3239.64

Cont.Cont. Once he was discharged, minimal Once he was discharged, minimal

support services continued to be support services continued to be supplied by hospital for supplied by hospital for $1500.00/month to be weaned $1500.00/month to be weaned over a 6 month periodover a 6 month period

Soft savings not including Soft savings not including medication $76514.64 annuallymedication $76514.64 annually

Over future life of file: $76514.64 Over future life of file: $76514.64 x 30 years = $2295439.50x 30 years = $2295439.50

We can make a difference, we We can make a difference, we do matterdo matter

Clearly document what you do, Clearly document what you do, how you do it-the CM on this how you do it-the CM on this example did not end up being example did not end up being taken to court by the IW’s taken to court by the IW’s attorney-he had nothing to take attorney-he had nothing to take her to court on..her to court on..

Cont.Cont. Ex: Neuropscyhological IME is scheduled with Ex: Neuropscyhological IME is scheduled with

Dr. A for August 6, 2004 to for Dr. A for August 6, 2004 to for neuropsychological examination. Last neuropsychological examination. Last neuropsycholological exam was performed Dec neuropsycholological exam was performed Dec 12, 1993 by Dr. B. IW’s injury is 14 years old 12, 1993 by Dr. B. IW’s injury is 14 years old and reassessment is appropriate & medically and reassessment is appropriate & medically necessary at this time to determine IW’s level of necessary at this time to determine IW’s level of functioning. IW has been notified by reg. mail functioning. IW has been notified by reg. mail and certified mail # 70041160000097634716 and certified mail # 70041160000097634716 with 14 days notice per LA State Statute as has with 14 days notice per LA State Statute as has his attorney, Lawrence L. Lawyer, cert. mail # his attorney, Lawrence L. Lawyer, cert. mail # 7004116000097634715 7004116000097634715

Continue to document every detail of what you Continue to document every detail of what you do, who you talk with, who you deal with, what do, who you talk with, who you deal with, what you mail and you will be able to come back in 1 you mail and you will be able to come back in 1 wk, 1 month or 5 years and know what wk, 1 month or 5 years and know what progressedprogressed

Assisting the attorneys…as Assisting the attorneys…as the LNCthe LNC LNC’s who have been WC CM’s have a LNC’s who have been WC CM’s have a

distinct advantage in helping plaintiff distinct advantage in helping plaintiff attorneys, they can assist with helping lay attorneys, they can assist with helping lay the ground work for their cases-they the ground work for their cases-they know the way the WC system works, they know the way the WC system works, they can anticipate the WC companies next can anticipate the WC companies next move or what their response might be.move or what their response might be.

Decipher the medical records and Decipher the medical records and anticipate the next medical move of the anticipate the next medical move of the WC CarrierWC Carrier

Assist with locating expert witnesses Assist with locating expert witnesses

Moving toward resolution…Moving toward resolution…

Always remember, the ultimate Always remember, the ultimate goal in any WC file is to move goal in any WC file is to move the file toward resolution-RTW is the file toward resolution-RTW is always first and foremost goal. always first and foremost goal. The fine line for the WC/LNC CM The fine line for the WC/LNC CM is dependent on which side of is dependent on which side of the fence you are working on….the fence you are working on….

The EndThe End

Thank you and please remember to Thank you and please remember to complete the session evaluation.complete the session evaluation.

If you have any questions, please feel If you have any questions, please feel free to contact me at:free to contact me at:

DV Consulting Co. LLC DV Consulting Co. LLC Dawn Vincent RN CRRN LNCC MSCCDawn Vincent RN CRRN LNCC MSCCHouma, LA Houma, LA 985-876-7801985-876-7801