Case Severity: What Factors are You Missing in Delayed RTW Cases?

Case severity tools like the ODG calculator play a big role in helping workers’ comp professionals predict return-to-work timing and costs based on the total claim picture. However, if you fail to look beyond the compensable diagnosis, you may find that your severity rating score doesn’t add up. Genex’s Mariellen Blue, RN, CCM, national director of case management services, explains in this podcast. 

Tom Kerr (TK): Welcome to Inside Workers’ Comp, a regular multimedia series in which subject matter experts discuss problems and offer solutions to top issues affecting our industry.

I’m Tom Kerr and today we’re speaking with Mariellen Blue who’s going to help us uncover problems with case severity scoring. Mariellen, thanks for joining us.

Mariellen Blue (MB): Thank you very much, Tom.

TK: First off, how does case severity scoring work?

MB: Whenever an individual sustains a work-related injury or illness, the length of treatment and the disability duration can vary significantly from person to person. And our challenge, in the workers’ compensation environment, whether it's from a claims management perspective or a case management perspective, is really to identify those claims that are most at risk for having a poor outcome and also those claims that are most likely to benefit from case management interventions to have a more successful case outcome.

In catastrophic claims, it's very easy to determine if that is a complex case that really requires further case management intervention, very focused interventions and claims management. However, in non-catastrophic claims, that determination really is not that cut and dry.

One of the preeminent tools that we use in workers' compensation for predicting risk and to benchmark treatment is the Work Loss Data Institute's Official Disability Guidelines, otherwise referred to as the ODG. And the way this works, in our system, we have created a link between data fields that are used in that comorbidity calculation, and they're pulled directly into, through our interface, into the ODG comorbidity calculator.

The output from that will give us what we call our case severity rating, which is the comorbidity calculator risk assessment score. This is a score that is given on a scale of 1 to 100 and it has five 20-point increment categories: low risk, moderate risk, cautionary risk, high risk and extreme risk.

TK: OK so let’s say an injured worker sustains a sprained knee he’s going to have a lower case severity score, right?

MB: Well, really with any type of injury or illness, but particularly in workers' compensation, you're really doing a disservice overall to the injured worker and to the claims administrator, if you are only looking at that compensable diagnosis because that really doesn't tell the whole story.

I'll give you an example with comorbidity calculator. Let's say we have an individual, 30-year-old male, and they have a diagnosis of a lumbar sprain and strain, so a low back injury. If I was just trying to benchmark this particular case using only the compensable diagnosis, using our case severity rating scale, this would be rated as a 33 which would be a moderate risk which is relatively low on the scale.

You might think, "OK, this isn't that difficult of a case. The estimated return-to-work date would most likely be in the range of 14 to 19 days." And you might think this maybe is not a complex claim. If you are an adjuster, you may or may not refer this due to that low score if you were using this tool.

We look at that same scenario for the 30-year-old male with a diagnosis of lumbar sprain and strain; however, this individual is a smoker, obese (which is a BMI of 30 or higher) have psychosocial issues and has been prescribed opioids longer than 30 days. Now we look at the comorbidity calculator and what our case severity score is and it has jumped to 75 which is a high-risk area.

So here's a claim that may have initially been perceived as maybe not needing very intense case management services. Bringing in those confounding factors, this suddenly becomes a case that is likely to not have that great of an outcome if left unmanaged.

TK: Thanks, Mariellen. In our next Inside Workers’ Comp, we’ll discuss strategies to help improve case severity scoring. Until then, thanks for listening.

Part 2

Genex’s Mariellen Blue returns to provide answers to issues dealing with case severity scoring to help prevent injured worker cases from spiraling out of control.

Tom Kerr (TK): Welcome to Inside Workers’ Comp, a regular multimedia series in which subject matter experts discuss problems and offer solutions to top issues affecting our industry.

I’m Tom Kerr and in part two of our series, Mariellen Blue reveals factors you might be missing when determining case severity scores.

Mariellen, in the last podcast you mentioned that case management plays an important role in uncovering comorbidities, could you elaborate?

Mariellen Blue (MB): When we first receive cases, whether it's telephonic or field, we're doing a very complete initial case assessment with that individual. Our goal is really to get a complete history, whether the history is related or unrelated to that compensable injury.

So looking … are there psychosocial issues? Are there even issues with literacy that need to be addressed? If an individual has an injury, but they're overriding other issues that they are more focused on, they are less likely to be compliant with their health care treatment plan or, sometimes, even understand what that health care treatment plan is.

If you are not looking at those other factors that maybe are preventing that individual from being compliant, preventing them from understanding, then you are not going to get the outcome that you would if you are addressing those issues as well. And it's not that we're saying these are things that need to be paid for under that workers’ compensation claim, but to take that time to give some suggestions to that patient to perhaps channel them, have them discuss it with their regular health care provider, or even give them information about community resources or other resources that can help with those particular issues.

TK: You had also mentioned data analytics. How is it used in improving case severity scoring?

MB: Our information on estimated return to work, length of disability, the case severity rating, are all items that we capture now in our database. We are also able, from an analytics standpoint, to now pinpoint exactly what are the driving factors that make certain claims at a higher risk than others.

So, some of the areas, such as psychosocial issues, smoking, obesity, diabetes, hypertension, opioid use, look at what the average scores are and the various scores for their population, and then be able to identify what are the confounding factors that might be elevating their particular risk.

You might have an employer population, we're reviewing those case severity ratings with them, but we see that one of the driving factors might be obesity or diabetes that's not properly managed. Although that's not related to the compensable claim, that's something that that individual employer may want to look at from an overall company standpoint through their regular group health provider or other type of educational initiatives that they can do to try to reduce that risk in their current employee population.

TK: So how can we improve on the case severity process in the future?

MB: One of the areas that we're looking at for future development with this new functionality and reporting capabilities is to be able to look at high-risk cases and then compare that to what are the cases that are having the most successful outcomes within those parameters.

So for those that we're getting very good outcomes — that we're beating return-to-work estimates, that we're having a very successful outcome — what are the things then, digging deeper, that the case managers working those successful cases are doing that we can then develop best practices and case management care paths so other case managers with similar cases would have a blueprint that drive a successful outcome in these types of case scenarios.

TK: Thanks, Mariellen. In our next Inside Workers’ Comp, we’ll look at strategies to improve return-to-work rates. Until then, thanks for listening.