1. Ferris, Kimberly A. RN, CCM

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We have all heard of the 3-point contact in the case management field, but in reality, there are four very important parties on each worker's compensation file. The 4-point contact is needed to obtain quality care with timely and cost-effective outcomes.


Injured Worker

For me, this is the No. 1 contact when I receive a new file. This is an opportunity for the case manager to begin a trusting relationship with the injured worker. Early intervention is critical to the outcome of a file, so case managers should obtain the file within the first 24 hr after an injury, once verifying that the case is compensable. The start of a conversation should include a brief introduction of your title and your role as a case manager. Many questions are asked at this time, whether as a field nurse in person with him or her or telephonically. You should be asking about his or her medical and work history, mechanism of injury, symptoms, current treatment plan, personal history, family/friend support system, and financial history. Financial history is especially important as many injured workers expect the workers' compensation system to replace their wages and benefits and are often dissatisfied by the realization that it does not. All of the above information is pertinent to the success of the file. At times, after a very thorough initial interview, it can be determined whether the injured worker will recover as expected or his or her injury may take on a life-limiting event.


This is also an opportunity to set short- and long-term goals and to confirm that the injured worker is in agreement. Goals should be realistic, matching their diagnosis and disability guidelines.


Contact with the injured workers should be constant, specifically after an appointment so that short-/ long-term goals can be refined for optimal recovery. Contact will remain with the file until the maximum medical improvement (MMI) is obtained and the optimal level of function has been obtained from the work site or a referral for vocational rehabilitation services has been obtained.



The provider is an occupational health physician/specialist/therapist or other, and he or she should utilize evidence-based treatment guidelines and support return to work. Building a successful relationship with the providers should begin at Day 1 with the consultation. A copy of the injured worker's job description and the employee demand analysis (EDA) along with work status form should be in the medical file for the provider to review. The provider should also have a clear understanding of modified duty opportunities within the workplace of the injured worker.


The injured worker should be reevaluated in a timely fashion for updated medical treatment examinations and treatment plans and reevaluation of work status. If multiple providers are involved with the file, the case manager's role is to keep all parties communicating with progress and about their treatment plan and is to refine short-/long-term goals. Duplicate treatment should be avoided; involvement with utilization review for medical necessity and appropriateness of treatment along with quality medical care and cost containment are essential for the file.


Communication with the provider continues until the injured worker obtains MMI or has been transferred out of the care.



Employer's involvement is extremely important for the success of the file. Because of confidentiality, medical information cannot be given to the employer but they must be updated on the injured worker's work status, whether disabled or able to return in a modified duty position. It is imperative that the employer supports recovery with return to work.


The case manager works together with the employer to formulate a return-to-work plan, modified duty positions, and tasks to be assigned, while the injured employee is recovering from his or her injury. Research has shown that the longer the injured worker remains off work, the less likely he or she will return to work. When injured workers return to work, they recover faster, and return to work in regular duty happens quicker when the injured worker remains working in a modified position. Time is of essence for the employer to become involved from the moment the injury happens; there is a common goal for the injured worker to remain working. The employer needs to be aware that the tasks assigned with modified work should be "meaningful" work. There is no motivation for the employee to return to work each day if he or she is taking up space and time and not working in a productive manner for the company.


If the injured worker is disabled, the case manager should encourage the employer to keep continued contact with the employee showing empathy. This shows compassion and concern and that he or she is a valued employee.


It is to the employer's benefit to have a return-to-work program in place. At times, the case manager must explain about indemnity to the employer. The less money the insurance company is spending to pay benefits, the lower the premium costs. Premium costs decrease for successful return-to-work programs in companies.


Remember that when the file is close to MMI and if the injured worker is left with permanent restrictions, it is not always feasible to have the employee return to the same job. The case manager and the employer need to put thinking caps on for other opportunities within the company. It could mean permanent job modification or restructuring of his or her position versus other opportunities within the company that the employee and the employer can benefit from. It may be beneficial to workers to have a vocational counselor become involved with the file for transferable skills and career goals of the injured worker.


Claims Adjuster

Once the adjuster has investigated the claim to decide whether it is compensable and has authorized the case manager to work on the file, ongoing telephonic/written contact is important for proper claims handling of the file. Ongoing written contact should include short-/long-term goals and case management action plan with time frames.


The case manager should update the adjuster of any medical and return-to-work changes on the file. The most important role of the case manager is to educate the adjuster regarding any concerns, inconsistencies of the injured worker, and red flags.


The case manager should work with the adjuster on the file to discuss medical treatment that may be needed including transportation and durable medical equipment that the case manager feels is appropriate to improve the medical status as quickly as possible. Adjusters should be familiar with evidence-based guidelines that include the standards for medical treatment, the length of the disability, and the state guidelines.


If the employer is not willing to work with the case manager for return to work in modified positions, it is best to discuss with the adjuster so that he or she may become involved to explain indemnity payments and how this affects the employer's company in the long term.


As you can see, in order for a worker's compensation file to be successful, it is essential for the case manager to collaborate with the 4-point contacts as noted above. These ongoing contacts throughout the life of the file will bring quality medical management and cost containment for the file.