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CM approach quickly resolves claims
Mental illness is the primary diagnosis in roughly 20% and the secondary diagnosis in up to 65% of all disability claims. Although the literature suggests that returning employees on mental disability to an active lifestyle and their working environment shortens the length of disability, many payers and employers alike are reluctant to encourage early returns to work.
"No one wants to touch a mental disability claim. Employers are uncomfortable with mental illness. They unsure how the employee will react in any given situation, and claimants stay out on disability for much longer than necessary in many cases," says Kenneth Millsap, BS, PTA, assistant vice president of loss containment for CIGNA Group Insurance in Philadelphia. "And we can’t expect all case managers to have a good handle on managing mental disability claims. These cases require nurses and psychologists with significant psychiatric experience."
CIGNA has turned to its sister company, MCC Behavioral Care in Minneapolis, to manage its mental disability cases aggressively and return claimants to the workplace. "When we get a mental disability file, our nurses look for certain parameters which may suggest that the claim is not being appropriately handled. If the file raises any red flags, we refer the case to MCC," says Millsap.
Some examples of cases recently referred to MCC include:
• files open for six months or longer;
• files with no clear treatment plan;
• files that indicate the claimant sees psychiatrist once a month for prescription renewal with no other therapy documented.
"We are trying to identify mental health claims at the earliest possible stage to start an appropriate treatment plan and get the claimant back to work," Millsap explains. (See stories on returning employees to the workplace and common myths about mental disability claims, p. 117.)
The referral program does help return claimants to the workplace earlier. In 1997, CIGNA conducted a pilot of the MCC referral program with several customers who had a high incidence of mental health disability claims with overwhelmingly positive results. Those include:
• 35% of the 250 claimants were determined to be ready to return to work full time.
• 38% of the claimants were placed in vocational rehabilitation or transitional work arrangements, with the goal of returning them to full- or part-time work.
• Average duration of mental health disability claims decreased by 15%.
Before CIGNA refers mental disability claims to MCC, CIGNA nurses collect all the available medical documentation from the attending physician. "We want the MCC psychologists to have a clear picture of where the claim stands and what’s been happening with the claimant to date," explains Millsap.
An MCC case manager, either a psychiatric nurse or a social worker/psychologist, contacts the claimant by telephone and conducts an interview to further clarify the status of the disability and the claim. Questions the case managers asks include the following:
• Are you in treatment at this time?
• What type of treatment have you received or are you now receiving?
• How has the treatment worked for you?
• What medication are you taking?
• How often do you take your prescription?
• Are you able to perform daily tasks?
• Do you participate in any recreational activities?
"Case managers gather the information from the claimant to identify any other red flags before contacting the attending physician for more information," Millsap says.
After interviewing the physician and documenting all findings, the case manager refers any questionable claims to a MCC psychiatrist for review. "The psychiatrist reviews the chart and then contacts the attending physician or psychologist for a peer-to-peer consultation," he says. "The MCC psychiatrist gives the attending provider feedback and makes recommendations for resolving the claim and returning the claimant to the workplace. They only make recommendations. Disability claimants have the right to receive any treatment they want, but we’ve found that the attending providers are very open to this type of peer-to-peer exchange."
Providers are more receptive to recommendations from the MCC psychiatrist than to recommendations made by case managers, Millsap says. "We’re finding we get much better results from peer-to-peer communication. The psychiatrist speaks to the attending provider as a colleague. The psychiatrist says, We’ve found these services or treatment very effective. Perhaps you should consider them for your patient.’ If it’s simply information about a new medication, providers listen to case managers. However, if you’re suggesting an entirely new treatment plan, it’s more acceptable from a peer."
After the case review is complete, MCC provides the CIGNA Group disability case manager with a comprehensive summary of current clinical, psychosocial, and occupational factors impacting the duration and outcome of the employee’s disability. This summary provides the information CIGNA needs to make a benefits decision.