Effective Case Management in SelectNet

The Pinnacol Assurance SelectNet Manual outlines the expectations of effective case management for the primary care physician (PCP). Here is some helpful information taken from the chapter on case management.

Assessing causality: The injured worker’s employer is liable only for compensation and benefits for work-related injures. And while the question of whether an injury is work-related or not is an administrative one determined by a claims representative or an administrative law judge, in some cases the compensability determination may depend upon the medical provider’s causality assessment. It is imperative that a provider’s medical reports clearly outline any causal connection between the on-the-job accident and the subsequent need for medical treatment.

Managing disability: When an on-the-job injury occurs, there are essentially four different occupational outcomes during the course of treatment:

• Return to full duty at the pre-injury job
• Return to modified duty, progressing toward full duty at the pre-injury job
• Return to modified duty, progressing toward ultimate change to a different job
• Off-duty status

Disability management means appropriately minimizing the effects of an injury by promoting early return-to-work and by emphasizing the worker’s “ability” rather than his or her “disability.”

Educating the injured worker: It is important for the medical provider to outline what the injured worker can expect and define the worker’s responsibilities with regard to the recovery process. This way, injured workers are active participants in their recovery, rather than passive recipients of medical care.

Initiating and managing referrals for specialty care: In SelectNet, only PCPs should initiate referrals. They are responsible for not only coordinating the initial appointment, but also for insuring that the specialist has all needed medical reports and diagnostics.

Medical management: In addition to cooperating with Pinnacol’s utilization management program, medical providers are required to use the medical treatment guidelines and utilization standards afforded under Rule 17 of the Colorado Division of Workers’ Compensation Rules. (Workers' Compensation Act 8-42-101(3) (III)(b)). You can find these guidelines by logging onto the Division of Workers' Compensation website.

Maximum Medical Improvement: The Workers’ Compensation Act of Colorado defines maximum medical improvement (MMI) as “the point in time when any medical determinable physical or mental impairment as impairment as a result of injury becomes stable when no further treatment is reasonably expected to improve.” The definition of MMI indicates that an injured worker’s need for maintenance care must not delay a finding of MMI. It is imperative that permanent disability be elevated at the same time MMI is reached.

You may find additional information about case management by logging onto the SelectNet website. and accessing the SelectNet Manual’s chapter on case management.