Managed Care in Risk Management


Photograph by Ian Hooton/Science Photo Library/Corbis

3,000 Years of Medical Expertise.

As of 2012, Zurich’s medical management division has almost 200 utilization review nurses and nurse case managers fully integrated into the company’s system. In fact, they average more than 10 years with the company, and over the course of their careers have more than 3,000 years of combined medical expertise. The nurses work side-by-side with Zurich’s claim professionals, looking at the same medical documents, communicating and conversing, and updating files, all in real time. The team is grounded in its collaborative “One Zurich” approach that emphasizes knowledge sharing and permits an effective and efficient facilitation of quality care, according to Dr. Nina McIlree, Vice President, Medical Management, Zurich in North America.

“Having our claim professionals working so closely with our nurses lets us make the right decisions quickly, and with the right expertise, whether it’s managing and facilitating care, assisting with the appropriate resources for the injured worker, finding the best doctors in the area, and so on,” says Dr. McIlree. “By having our nurses integrated so closely with the claims process, we’re also able to be a medical resource for the claim professionals on claims that may not need active nurse case management, but would benefit from quick medical expertise to answer a question.”

As Zurich employees, these nurses also have a clear understanding of the company’s approach. This means doing the right thing quickly, and handling each worker’s case with integrity, compassion and clear communication. In sum, it means working together toward the best possible outcome.

“Our mission is to assist injured workers in the workers’ compensation area to receive quality care effectively and efficiently, to optimize their recovery, maximize their function and quality of life, and return to work as quickly as possible,” Dr. McIlree says.

Another significant point of differentiation for Zurich: its medical team doesn’t only support the workers’ compensation claim professional. Zurich has developed a program in collaboration with claims and risk engineering for a proactive return to work approach. The company’s nurses, trained by its risk engineers, use their expertise to identify—by reviewing clinical documents and through discussions with the employer—issues that can be obstacles to returning to work.

“By having the nurses integrated into the Zurich culture—understanding our processes and working with allied departments to facilitate all these aspects of return-to-work—we’re able to bring the medical expertise to where it’s needed,” Dr. McIlree says.

One major issue in getting people back to work is the utilization of opioids, which has become both an industry and general health epidemic. Using the team’s medical expertise, Zurich has built a program with its pharmacy benefit manager to support the claim professional in dealing with these issues. Through the pharmacy benefit manager’s database of prescriptions, Zurich is able to look at potentially unsafe prescribing patterns by watching for certain triggers as each individual claim is reviewed. This review allows the company to identify potential risks, such as high-dose prescribing, addiction or diversion (for example, selling the prescription and/or receiving the same medication from multiple providers without the providers’ knowledge). When these risks appear, Zurich’s medical team reaches out to the providers and engages in collegial communication.

“We’re seeing some significant impact,” says Dr. McIlree. “Providers are welcoming these discussions because it’s an opportunity for them to see how their care is being possibly misused, abused, or contributing to potentially unsafe outcomes. This dialogue engages providers to re-evaluate their pain management strategy to optimize the injured worker’s care.”

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