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Claims case study: Early nurse referral can result in $6K-$26K average savings

September 28, 2016

Nurse case management can have a clear impact on promoting quality care, reduced loss costs and return to work.

Vice President, Medical Management

Her areas of responsibility include Zurich Care Plus, Medical Bill Review, Medical Professional Case... About this expert

nurse working on paperwork

Nurse case management can deliver multiple benefits to injured workers:

  • Medical knowledge to address health and wellness issues
  • Encouragement and guidance to injured employees
  • Assistance in facilitating timely recovery and locating quality care
  • Guidance in navigating a complex medical environment

As an industry, we’ve known these things for a long time. What we can now demonstrate is the quantifiable impact that nurses can have on total claim costs and closing rates. 

In an effort to better understand and manage loss costs while also promoting quality care, customers have questioned:

 

What is the value of having a nurse on the claim file earlier?

Zurich’s analysis of nearly 28,000 claims showed that the timing of nurse case manager referral can have significant impact on the total cost of a claim as well as the closing rate. 

The analysis looked at three distinct referral time frames:

  • Early: 4-30 days
  • Late: 31-90 days
  • Extremely late: After 90 days

Ultimately, the analysis confirmed longstanding belief: early referral of claims is optimal. 

When nurses are engaged early, the result can be an average $6,000-$26,000 total savings per claim, with nearly 50% of that savings in medical spend. 

 

Early Nurse Case Manager Referral Benefit 

Early referral benefit charts

Source: Zurich Closed Claims Data 2012-2015



 

Zurich’s analysis shows that early referral claims also closed much sooner and the pattern is consistent across complexity levels. For example, for moderately severe claims, 69% of claims referred within 4-30 days closed within four quarters, compared to only 23% of claims referred after 90 days.

All complexity trend charts

Source: Zurich Closed Claims Data 2012-2015

 

How can you identify claims that may benefit from a nurse case manager?

Not all claims will warrant a nurse case manager and, among those that do, the necessary level of involvement can vary. In addition to claims professional experience, advanced technology can help provide empirical insight into when a workers’ compensation claim may benefit from medical professional guidance. The application of predictive models is one way that insurance providers can help deliver timely and targeted nurse intervention. 

Zurich has been developing advanced analytics capabilities for the past decade. From a claims perspective, predictive models run at first notice of loss and continuously update as new information is added. The models draw on millions of data points to evaluate the importance and impact of key factors at specific points in time (e.g., opioid use). These models can generate automated alerts to claims professionals and automated referrals to nurse case managers when needed.

Example: A claim is reported where the injury appears to be a minor shoulder strain due to a slip and fall at the insured’s construction site. However, based on the data, the predictive model assesses the risk to be high at the onset of the claim. A Zurich nurse case manager is engaged and it is determined that the shoulder pain is actually referred pain from a neck injury. The nurse can proactively assist in getting physical therapy and appropriate medication management, which ultimately can result in medical improvement and early return to work. As a result of the predictive model, Zurich is able to respond to bring together various resources earlier in the claim to help improve the outcome. 

Integrated solutions, such as nurse case management and predictive analytics, can help drive a medical management program designed to deliver distinctive risk insights, claim cost savings and clear benefits.

 

The information in this publication was compiled from sources believed to be reliable for informational purposes only. All sample policies and procedures herein should serve as a guideline, which you can use to create your own policies and procedures. We trust that you will customize these samples to reflect your own operations and believe that these samples may serve as a helpful platform for this endeavor. Any and all information contained herein is not intended to constitute advice (particularly not legal advice). Accordingly, persons requiring advice should consult independent advisors when developing programs and policies. We do not guarantee the accuracy of this information or any results and further assume no liability in connection with this publication and sample policies and procedures, including any information, methods or safety suggestions contained herein. Past results and prior performance are not indicative of future outcomes. We undertake no obligation to publicly update or revise any of this information, whether to reflect new information, future developments, events or circumstances or otherwise.  Moreover, Zurich reminds you that this cannot be assumed to contain every acceptable safety and compliance procedure or that additional procedures might not be appropriate under the circumstances.  The subject matter of this publication is not tied to any specific insurance product nor will adopting these policies and procedures ensure coverage under any insurance policy.

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