Managing Workers' Comp Costs with a Nurse Triage Program

When a workplace injury occurs, employers with no medical training often must determine the severity of the injury and direct an employee to appropriate medical care.

They may have to make on-the-spot decisions about whether the injury is minor and requires only first aid treatment or an emergency or urgent care visit. Other times, the employee may need to be evaluated by a specialist.

These decisions are not only vital for the care and treatment of an employee, but they also are a huge driver of workers' compensation (WC) costs.

Medical treatment accounts for the largest proportion of costs in WC claims, with roughly 80% of these costs spent on physician and facility services. These expenses, which are subject to inflationary factors such as the consumer price index, increased at a rate of 2% per year between 2012 and 2021.

One solution to helping injured employees with their claims while controlling claim costs at the same time is a nurse triage program. This article describes what a nurse triage program is and how you can implement one in your company.

What Is a Nurse Triage Program?

Nurse triage, also called nurse concierge or nurse consultation, is an injury platform or hotline that allows employers to respond to workplace injuries soon after they occur. A medical professional—often a registered nurse—helps employees determine the best steps to take after an injury by providing self-care instruction or directing the person to the appropriate medical care. This immediate action can help reduce lost time at work and unnecessary visits to the doctor or hospital.

There are two primary types of nurse triage programs: those offered by WC insurance carriers to their insureds as part of their policy package and those provided by third-party vendors.  

The cost of these programs varies, but most service providers charge by the cost per call. The average is $90 per call. Some providers only charge a per-claim fee if the triage call results in an official claim.

Nurse triage programs can help reduce lost time at work and unnecessary visits to the doctor or hospital.

Due to the high return on investment associated with nurse triage, many insurance carriers will absorb the costs and offer the service to their premium-paying customers free of charge. 
Some third-party vendors have a tiered pricing system, charging a flat rate depending on the customer's loss history and projected number of annual claims. Additionally, there are sometimes implementation, enrollment, or yearly fees. 

How Does the Nurse Triage Process Work?

While some nurse triage platforms are dispatched to the job site, they typically provide a 24/7 hotline or virtual call for employers and employees to call in a workplace injury and obtain medical advice when the injury happens.

A trained nurse or medical specialist then assists employees with determining the most effective medical care needed after the injury. This care may include:

• Self-treatment and first-aid instructions
• Telehealth visits
• Urgent or emergency room care
• Referrals to a specialist

If the nurse or medical specialist determines that only self-care is needed, most triage coordinators will follow up with the employee in 24 hours to assess whether a higher level of care is necessary. If more treatment is indicated, the coordinator will file the WC claim on behalf of the employer to the insurance carrier.

They will work with the carrier and have access to designated occupational clinics for appropriate treatment referrals. This communication ensures that no out-of-network locations are used, and medical care continues on track.

When an employee reports an injury to the hotline, the nurse not only digs into a complete injury-body mechanic analysis but also obtains the employee's complete medical history. Pre-existing conditions can impact treatment decisions. For example, an employee with a seemingly minor foot injury who also has co-morbid diabetes will have a greater risk of complications than an employee who does not have diabetes.

The nurse will also inquire about substance use to make suitable medication recommendations.

The nurse does not promise the injured employee benefits or claim acceptance. Their purpose is strictly to obtain the injury details and provide medical guidance. For example, the nurse will note any issues with the claim's compensability at the time of the intake but defer to the WC claims adjuster.

What Are the Benefits of Nurse Triage?

Working with a nurse triage partner can provide a return on investment and return on value for both employers and employees. Here's how.

• Lower claim costs. Many triage vendors report over 20% reductions in total claim costs and over 40% in intake calls, resulting in no claim setup due to successful recommendations for self-care. Triage service providers are also finding a reduced litigation rate on claims where triage is implemented.
• Reduced administrative burden. By outsourcing to a medical professional when an injury occurs, employers can reduce their administrative and medical decision-making burden. Nurse triage ensures appropriate and timely claim submissions to the WC carrier, thereby reducing both claim frequency by preventing incidents from becoming unnecessary claims and lag time for incidents warranting a claim.
• Fewer delays. Proper vetting of injuries in the initial stages improves the accuracy and quality of medical care, reducing delays. Since injured employee recovery is based on adequate medical treatment, lost time days may also be reduced. 
• Reserving claims. Triage can help stratify injuries, which may assist adjusters with more accurately pricing claims so that reserves aren't higher than necessary. This factor may, in turn, decrease ex-mods.
• Fewer urgent care visits. Nurse triage programs help prevent unnecessary urgent care and emergency room visits, diminishing these costs. Similarly, incidents effectively managed as "self-care" will lessen OSHA recordables. 
• Recordkeeping. Another advantage of triage is that since all calls are recorded, the transcripts can be used to defend later disputes regarding the nature and severity of injury.

Nurse triage also offers intangible advantages for injured employees, such as the feeling of support and advocacy by medical professionals.  

Additionally, a more streamlined process reduces delays and frustrations, which sometimes lead to litigation. In fact, some triage service providers find reduced attorney involvement in claims where triage is implemented. 

What About the Cost?

If an insurance carrier's program is free, a nurse triage program is almost a no-brainer. However, it's essential to understand any fee components in order to complete a cost-benefit analysis. The higher an employer's claim volume, the more the use of a triage program will make sense from a financial perspective.

The program's success depends on proper communication, which requires mandatory use, training of internal front-line staff, and consistent adherence to protocols. If there are few claims, an employer may be better off with a simpler triage program or internal administration.

How to Get Started

The first step is to check with your insurance carrier or broker to see if they offer nurse triage. If so, schedule an introductory call to obtain information about the cost and other details associated with the program.

It makes sense to pilot programs offered by insurance carriers to their customers for free or at a low cost before contracting with a third-party vendor.

Obtaining a loss run to analyze claim volume is essential to estimate the various triage program costs since fees are based on an employer's claim history and projected losses. Third-party vendors typically offer free informational calls, including a formal presentation and system demo. You can ask your broker to take the lead to facilitate such meetings.

Obtain a loss run to analyze your company's claim volume so you can estimate nurse triage program costs.

Employers should ensure that all pertinent stakeholders are included in these sessions. Some might wish to have legal counsel present.

Once you decide on a triage program, schedule 6 to 10 weeks for implementation. During this period, you will set up internal contacts, communicate information about the program, and train staff on the new workflow for handling injuries.

This timeframe also allows the triage service provider time to establish locations, the list of team members responsible for calling in injury reports, and physicians in their database. Some triage providers help employers train their staff via virtual sessions and even provide template notifications for posting to their intranet or physical work sites.  

While a nurse triage program should not replace a 911 call in the case of an actual emergency, a well-structured program can offer rapid and accurate responses to injuries, giving employers and employees peace of mind and reducing WC claim costs.