Advocacy-based care and cost savings for your high exposure claims.
Supporting medically complex claims
Complex and catastrophic claims account for a small percentage of a payer’s claims yet represent a disproportionate share of total claim costs. These medically challenging claims typically involve multiple care providers and a host of biopsychosocial factors that can impact injured employee and patient recovery.
Rising’s field case management (FCM) services are provided by a team of goal-oriented field, vocational, and catastrophic nurse case managers with strong clinical backgrounds and regional knowledge of community hospitals, physicians, therapists, and other providers delivering care.
Our services include:
- Conducting risk assessments
- Providing advocacy-based nurse oversight to support the injured employee/patient recovery
- Evaluating appropriate care options in collaboration with treating providers and caretakers
- Coordinating medical and ancillary care required for successful treatment
- Monitoring and addressing recovery risk factors throughout the claim lifecycle, including biopsychosocial issues
- Accompanying employees/patients to appointments
- Recommending additional clinical reviews to assure medically necessary, evidence-based treatment plans (e.g., utilization review, peer review, physician file review, independent medical exam)
- Supporting transitions from the hospital to home and work settings, as applicable
- Educating and motivating injured employees/patients, facilitating all aspects of their recovery, rehabilitation, and return-to-work process
- Conducting ongoing, productive communication with all claim stakeholders
- Delivering positive outcomes
Rising case managers include registered nurses (RNs) and certified case managers (CCMs) and all have significant experience managing complex claims. Our case managers also hold certifications in occupational health, orthopedics, legal nurse consulting, and life care planning.
FCM for non-complex claims
Some claims require heightened attention and clinical coordination even if they are not deemed overly complex or catastrophic. Other reasons for using FCM include when:
- The treating physician has not documented or communicated a clear treatment plan for recovery or return-to-work, as applicable
- The treatment plan is outside of standard treatments of care
- The injured employee’s/patient’s function and/or symptom management has not progressed, activity levels have not been advanced, and/or the plan of care has not been effective
- An onsite medical advocate/liaison is needed (e.g., medical tourism cases)
FCM + Bill Review, a powerful combination for improving outcomes
For customers who utilize Rising’s medical bill review services, there are additional program benefits:
- Evidence-based alerts for FCM intervention fueled by our customers’ claims and bill review data
- 1-click FCM referrals in our client web portal, with pre-population of claims data in form fields
- Medical records are already available to Rising, eliminating claims professionals’ administrative involvement
- Existing data feedback loop can be used to measure FCM intervention effectiveness