Employers are required by federal and state laws to carry workers' compensation (WC) insurance, provide comprehensive occupational medical services for work-related injuries and record certain work-related injuries for the Occupational Safety and Health Administration (OSHA).

The best way to substantially reduce the number of WC claims and OSHA recordable events is to develop a comprehensive medical management system. A medical management system is designed to prevent, treat and manage occupational injuries. This systems-based approach to medical management should not be confused with a "band-aid trailer" or a "first aid station."  And if your medical management system is operating effectively, it should provide a demonstrable return on your investment in its implementation and maintenance.


The objectives of a medical management system are to:

  • Manage all patient encounters
  • Deliver nationally-accepted standard of care
  • Earn employee respect and comfort level
  • Create a partnership in the prevention and treatment of injuries
  • Provide specific management oversight to ensure an effective system

Case Management

An effective medical management system requires the hands-on case management of all patient encounters, both those treated onsite and those referred to offsite providers. The first step in this management approach is to treat the injuries according to the accepted standard of care. Next, identify injuries that fall under the first-aid determinations established by OSHA. Many times injuries treated offsite fall under the definition of medical treatment rather than first-aid because of certain treatments rendered at an emergency room or clinic.

A primary goal in case management is to keep injured employees onsite. If the worker goes to an offsite care facility, they will still be paid while in the waiting room, and if accompanied by a supervisor, this doubles the indirect cost of waiting. And, every time an employee visits an offsite clinic, the clinic is going to send the employer a bill, which will increase WC costs and increase your Experience Modification Rate (EMR).


A large number of injuries that would be generally considered OSHA recordable can be managed onsite.  For instance, simple lacerations that receive one or two sutures can be treated onsite with a sterile wound adhesive (the same product used in hospitals)

If it is determined that a case should be referred to an offsite provider, the onsite medical management representative will control the situation and function as the patient's advocate to return them to duty in a healthy, cost-effective manner.

Any clinic or physician visit should be pre-qualified, and referrals should be with the most appropriate facility or clinician. For example, a worker with a particle in his/her eye should not be sent to the emergency room or a clinic, but referred directly to a pre-qualified ophthalmologist. This will prevent an unnecessary bill.   It could also save a recordable report since the ophthalmologist was pre-qualified. (The pre-qualification of a provider is very detailed and too complex and lengthy to be included in this article.)

The medical management department should be attentive to any medical treatments or modalities that appear excessive, for instance, physical therapy or chiropractic treatment are notorious for abuse. In addition, the medical department should assertively manage all WC cases. This might necessitate involving investigators early and aggressively in suspected malingering cases. The medical management department should:

  • Communicate daily with injured employee for the first week. Bi-weekly after the first week.
  • Communicate with offsite provider after each visit.
  • Communicate early with corporate WC in questionable cases.
  • Communicate with third-party administrators (TPA) and/or carrier for reserves that seem too high.
  • Have TPA/carrier close out claims as soon as employee is back to full duty (as allowed by state laws).

Standards of Care

The medical management department should deliver the accepted national standard of care every time. This results in fewer offsite referrals, and fewer referrals mean fewer workers' compensation claims, lessening the chance of needless OSHA recordables. A high standard of care and treatment also helps employees get right back to work with minimal lost productivity.


Providing accepted standards of care and paying attention to employees' needs also helps avoid litigation and establish an excellent working relationship with employees.

An integral part of delivering the accepted national standard of care requires that the medical management department determine the level of care to provide. Here are the options:

  • Emergency Medical Technician/Licensed Practical Nurse: This is the lowest level of standard care. This level can treat approximately 40 to 50 percent of injuries onsite. The advantage of this level is the cost, while the disadvantage is the relatively low percentage of patients treated onsite.
  • Paramedic/Registered Nurse (RN): The next highest level of care, 90 percent of injuries can be treated at this level. This is by far the best level of care to use due to the positive ratio of price to onsite treatment.
  • Physician Assistant (PA)/Nurse Practitioner (NP): The PA/NP level is unique. It has the ability to care for more than 97 percent of injuries onsite. However the cost is nearly double, therefore, the small increase in onsite treatment percentage does not justify the large increase in price.
  • Physician: Obviously this is the highest level of care available. However, the price is significantly higher than the PA/NP level, and can be as much as four times the cost of the paramedic/RN level. The physician does have the ability to treat nearly 100 percent of injuries.

*Note: Some states may dictate the scope of practice of various providers and the information provided here is meant to be a general guide.

There are many published standards or requirements that may be or must be met and/or maintained by the medical management department including the Drug Enforcement Administration (DEA), State Boards of Pharmacy, State Offices of Emergency Medical Services and State Boards of Nursing among others. 

Employee Confidence in the System

The respect and confidence that employees have for the medical management department is vital to the success of the entire system. There are a number of states where employees have a choice of providers, and if the employee is comfortable and feels confident in the care being rendered, he or she is more likely to choose to stay onsite to receive medical care.


The appearance of the onsite clinic is very important to maintain the confidence of employees, and this confidence can be inspired simply by aesthetics such as the providers' uniforms and the clinic's professional furnishings and equipment.   Building employee confidence can also be as complex as helping with issues regarding non-work related pathologies.

Partnerships that Work

Establishing partnerships is essential to the prevention and treatment of injuries. Begin by evaluating local medical providers, and grade the results. Then establish working relationships with these offsite treatment facilities and providers to ensure they are philosophically and operationally aligned with the goals of the medical management system. Through these relationships, the medical management department can establish panels of specialists that are pre-qualified in the same manner that subcontractors are pre-qualified.

The relationship between the medical management department and the construction manager's (CM) safety department is one of the most important. In truth, the medical management department should function as a member of the "safety team," and work directly with the employee, foreman, general foreman and superintendent regarding work modifications that may eliminate all possible lost time injuries. The medical management department should establish a data management process, which, with the cooperation of the safety department, can be used to track, trend and analyze safety incidents with the goal of decreasing accidents or safety violations through prevention.

The medical management department can provide health and safety related services and information that may fall under the auspices of the safety department such as  substance abuse testing, OSHA respirator physicals, post-hiring physical exams and various types of surveillance testing such as lead, asbestos, cadmium, benzene, etc. The medical department can also provide such occupational health items as influenza vaccines.

Medical Department Oversight

An operational infrastructure should be created to verify that personnel and processes affiliated with the medical management system are being used and improved, with special attention paid to the appropriateness of the level of care as well as equipment used. Is the level of care provided by the medical management department appropriate for the construction project's size, location, duration, peak manpower and other occupational health issues? Is the medical equipment appropriate for the level of care provided? Does it contribute to employees' confidence in the medical department and will it attract top-rate medical personnel?

How Do You Know When It's Working?


An effective medical management system increases a CM's profits by assisting them in meeting their project schedule and construction budget. This is achieved because there will be fewer WC claims, which means fewer WC insurance deductible payments. The deductible limit for a CM's projects can sometimes be as high as $250,000 to $500,000. With fewer WC claims, CMs can afford to raise their deductible, further increasing their profits. Fewer WC claims also lead to insurance premium rebates at the project's final insurance audit because actual losses are lower than projected losses. Having fewer WC claims also leads to lower future insurance premiums, which is a significant cost saving that can be used as a competitive advantage when the CM bids on future projects.

A medical management department that treats and keeps injured workers onsite increases worker productivity. Most minor cases can be treated in less than thirty minutes and the employee can return to work. If an offsite facility is used, the employee must be escorted to the clinic/emergency room (thus two employees are losing productivity), and the wait can be up to four or six hours, depending upon the facility used.

And finally, treating first aid injuries through the onsite medical management department leads to fewer OSHA recordables, which leads to increased competitiveness in obtaining new work because safer CMs are preferred.

In short, when hiring CMs to manage their construction projects, many project owners evaluate the CM's safety statistics in the same way that they evaluate the CM's financial bids. For CMs, consequently, the WC financial savings remains a competitive advantage, and the CM also has the advantage of a better safety record and lower OSHA statistics as an additional competitive edge.

Construction Business Owner, January 2010