Dawn Moore
Senior Director, Utilization Management
Tom Kerr (TK): Partnering with a strong telephonic case management program can go a long way in helping payers boost their return-to-work outcomes. But how do you go about finding the TCM program that’s right for you? On today’s podcast Dawn Moore, joins us today to talk about TCM program customization. Dawn, thanks for joining us.
Dawn Moore (DM): Thanks for having me. I appreciate it, Tom.
TK: So, when you’re tailoring a TCM program to a buyer’s needs what are the initial considerations you look at?
DM: So, customers might have programs that they somewhat manage on their own. We have other prospects where they don’t do anything at all. So, the first opportunity is just doing a needs assessment on what clinical services from Genex we can offer the client to be able to supplement what they do.
We can do everything from intake all the way through triage to case management referrals to other additional clinical services, but some programs have staff that manage parts of their program. So, the fun part about my job is just doing that needs assessment, uncovering what additional Genex clinical resources we can implement to be able to elevate their program.
TK: What are some customer pain points you try to address with a customized TCM program?
DM: I think staffing definitely is a challenge that a lot of our customers have. Recently, we had one program where their medical director was out on pregnancy leave and our physician advisor team was able to supplement that.
Outside of the staffing, I think that the resources and the bandwidth — everything from a quality assurance perspective, licensure perspective — our clients start to understand the gravity of everything that’s involved to be able to just maintain that operation.
So, knowing that Genex is an organization that has the bandwidth, the structure, and the support and resources is often why we’re asked to provide those services versus the payer doing things in‑house.
So, specifically talking about telephonic case management, we have case managers who work from home, but we also do have case managers that sit on-site with a client as well in those very unique programs.
So again, that needs assessment, really listening to the client. I think Genex does a great job with demonstrating or sharing a program or recommendation that will fit into what the needs are versus coming to various clients with our best‑in‑class program where maybe that particular client already does some of the services in house.
When we’re working with our clients, we have several timeframes of when we touch base with them to ensure that we’re meeting their needs, that we’re answering the questions, that we’re delivering the right service.
So that communication part of it I feel like we do a really great job on, but no two programs look alike. I think if you were to ask our clients, every client feels like their program is most unique. And from the delivery perspective, Genex does a great job of understanding what those needs are.
There may be a lot of similarities as far as results — what they’re looking for, like successful return to work, medical management — but the process, the resources that we deal with, may be a little different.
So, the fun part of what we do is the ability to take best‑in‑class, but then bring that customization to each program we deliver.
TK: When you talk about TCM program customization, how does your approach vary from customer to customer?
DM: We have some customers where we may have an onsite presence and a work‑at‑home case manager. We may have some clients that are all work‑at‑home case managers. So, from a staffing model sense, there might be some variances there.
Outside of that, we have great artificial intelligence that we’ve been navigating through many, many years, within our organization, really looking at data components. So, we have some clients where we’re fully integrated.
We have EDI interfaces from claims feeds to notes interfaces, all those great things, and we also have clients that because their inventory or claim count is lower, it’s a little more manual.
I would say the majority of our clients rely on case managers to get them to at least a full duty or an MMI or medical treatment conclusion. So, it’s really looking at what they have, how we complement those services, how they would like to communicate.
But, ultimately, if you were to look at the end result, most of the programs end with the ability of successfully getting their injured employee back to work successfully and minimizing medical exposure.
TK: What about risk modeling? Can you explain that to me? Is that a new tool or something you’ve been using for a while?
DM: Genex has been doing some form of risk modeling for over 20 years now. I think over the years it’s evolved with a lot more sophistication, including a lot more data elements.
We do a beautiful job utilizing data to make meaningful decisions. And so, on the front end, we’re able to complement a manual triage process by looking at data points, and we call it Referral Expert. That has evolved into what we’re now calling Engage. It allows us to really look at data elements within a claim that gives a high probability of identifying cases that should be managed, cases that should possibly be triaged, and cases that possibly would be closed. That really gives our clients an additional set of eyes that are constantly looking at data, which is a great decision maker.
So, a lot of our programs that may have started very manually have over the years transitioned to either complementing manual with some sort of artificial intelligence like Referral Expert or Engage, which helps adjusters who may know and anticipate certain concerns they have on the file that aren’t going to be picked up in a data element. So that’s why I think programs that have a little combination of both find the best value.
TK: How do you measure the success of a customized TCM program?
DM: I think Genex does it from all lenses. So, we look at it from a perspective of financial return on investments. That’s obviously important. I often tell clients, “I want to be a good steward of your money. I want to ensure that we’re using your money wisely as if it was ours.” So financial outcomes, looking at return to work, those things.
From a medical perspective, along the same lines, we want to be ahead of evidence‑based guidelines. So, are we successfully able to get your injured employees to return to work? What is the percentage? What does the medical spend look like?
From an overall program perspective, we partner with our clients who are willing to share their claims data. Genex does an outstanding job with stewardship or partnership meetings where we actually look at claims data to share with them the impact that our clinical services are making on their bottom line. So, ultimately, when we share results, it’s based on cases that we’re managing. Marrying that to claims reporting analysis that we do, gives them a little bit more grit on how they’re performing at their bottom line. So really having both of those key metrics makes for a strong story.
Outside of that, being a nurse myself, we look at case outcomes, right? I spoke to return to work and the medical, but ultimately, we do all this great work for the injured employee, right? So, I think Genex does a great job of extending that kind of outcome measurement by looking at impact statements that we put in our case management system.
We also do surveys partnering with our clients asking these injured employees, “What are we doing well? How do you feel our clinical resources helped you navigate the return-to-work process or disability process?” Because I manage some businesses that also do short‑term, long‑term, FMLA and integrated disability.
But I think that’s a unique ability to be able to say we look at outcomes not just from the obvious financial and medical, but we also look at it from why are we doing all of this, right? We’re engaging these services to ultimately help the injured employee.
TK: Can you define the value of early telephonic case management intervention?
DM: The data speaks to it. We have umpteen documents and case studies and data mining that show the value of getting clinical resources earlier on the claim. The earlier you’re on the claim you establish that rapport with the injured employee, you’re able to establish those short‑term, long‑term goals to get that successful return to work. Obviously, when you get earlier return to work, you have less indemnity exposure, so you get injured employees back to work successfully you have the happier employee.
We stick to that story as far as the value of early intervention from a data or reporting perspective, but also when we are receiving feedback from the injured employee, oftentimes we get the feedback from them saying were a great medical resource.
We were able to answer certain questions that maybe a claims examiner couldn’t answer, or maybe even a doctor didn’t take the time to answer. So, from a larger employment retention perspective, I feel like a lot of clients come to Genex for this added value, almost benefit service, where they want to take care of their employee population better.
So, by having telephonic case managers available at the point of time where injured employees really need someone, we have found it’s less likely that employees will hire attorneys to litigate for them. They’re employees that actually are retained by their employer even after a significant injury. So, I think, ultimately, early intervention and that outreach to the employee has so many great benefits. Not just from the time when they are injured, but also from a longevity employment perspective.
TK: Thanks, Dawn. In our next podcast we’ll talk about another challenge facing payers, the provider shortage and how it’s affecting home health. Until then, thanks for listening.