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

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

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.

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.