Paradigm does not provide medical or health care services. We provide case management services. Although we contract with licensed nurses and physicians to oversee and manage a case, our contracted nurses and physicians do not provide the injured worker with medical care. Instead, Paradigm’s contracted physicians and nurses consult and collaborate with the injured worker’s various treating physicians to provide continuous onsite case management. Our contract physicians and nurses may recommend that the injured workers get treatment at certain health care facilities but they do not direct, nor do they provide, medical or health care services.
Under these circumstances, the abrogation (early termination) terms of the contract will apply. In this instance, Paradigm’s fee is based upon a standard percentage gross up of the total amount paid by Paradigm, not to exceed the original contract price. Once both parties acknowledge the condition for abrogation, Paradigm will complete a full financial reconciliation within 90 days and provide the details for final action to the client for confirmation.
Paradigm will provide authorization for those services addressed in the Outcome Plan. Any requested services for which authorization is questioned will be directed to the client or their Utilization Review Organization for determination. Paradigm does not perform IMEs.
Paradigm’s contract price for catastrophic cases includes all compensable medical expenses. Managing payment to providers is an important element to influence an outcome focus with the providers and to eliminate risk and volatility for the client during the course of the contract.
No. The Medical Directors are practicing physicians and leading specialists in their fields selected to provide Paradigm with the best expertise available. The large majority of the nurse case managers are independent nurses who specialize in catastrophic and complex injuries, with an average of 19 years’ case management experience. They have been carefully selected and trained to work within the Paradigm framework.
No. If clients choose not to accept a Paradigm contract, the case will be transitioned to a non-Paradigm nurse case manager chosen by the client.
Paradigm will request and gather medical reports on all assigned cases. Copies of admission and discharge summaries, operative reports, evaluations, etc., will all be forwarded to the claim professionals as they are obtained.
Upon receipt of referral, Paradigm assigns a Medical Director to review the case and reach out to the treating provider(s) to determine the diagnosis, prognosis, anticipated treatment plan. The Paradigm Medical Director elicits the outcome goal from the treating provider’s perspective and evaluates willingness to adjust the treatment plan and accept Paradigm’s involvement if indicated. If Paradigm’s Medical Director determines that Paradigm involvement is warranted, Paradigm will assign a clinical team, including an onsite nurse case manager to work in conjunction with Paradigm’s Medical Director. Paradigm’s nurse case manager meets with the injured worker to begin the management process, leveraging a bio-psychosocial approach. The Paradigm Management Team develops a management plan which outlines clinical issues, probable course of recovery, and likely services needed to achieve an optimal outcome. However, the injured worker’s treating providers direct care, not Paradigm. Paradigm engages in active, onsite case management, working collaboratively with the claim professional to ensure proper coordination of care to achieve the specified outcomes.
Once a referral is made to Paradigm, the parties identified as requiring clinical updates will receive direct communication from the Paradigm nurse case manager. In the case of acute catastrophic injuries, communication will occur shortly after the nurse case manager receives the case information and then within 24 hours of completing the initial on-site assessment. Following this initial assessment, Paradigm will provide updates at least weekly to the claim professional until the Outcome Plan contract is accepted. Similar communication approaches are taken for referrals involving legacy catastrophic injuries and complex pain conditions. For cases under active, ongoing management, Paradigm develops monthly reports as well as additional telephonic or email communications as requested or any time a significant event occurs.
Immediately following notification of a catastrophic injury, Paradigm assigns a clinical team, including an on-site nurse case manager and a physician specializing in the reported injury. Paradigm’s nurse case manager will make early contact with the claim professional to ensure effective coordination. Paradigm will complete an on-site assessment of the injured worker typically within 24 hours, including contact with the family as soon as possible to gain a full understanding of the injured worker’s diagnoses and related conditions and to begin care coordination as applicable. Following the assessment, Paradigm’s Management Team will develop a contract proposal in the form of an Outcome Plan that outlines all of the clinical issues, the probable course of recovery, likely services to achieve the optimal outcome and the case rate and outcome guarantee. During this development period, which generally takes 2-3 weeks, Paradigm will retain responsibility for active, on-site case management, working collaboratively with the claim professional to ensure proper coordination of care.
Each situation is unique, so be sure they have a clear and timely understanding of the severity and complexity of the injury and the financial implications for achieving optimal outcomes. For new and legacy catastrophic injuries, stress that Paradigm is limiting the medical cost volatility by offering a fixed price contract for a guaranteed outcome or time period. Paradigm’s specialized management results in 40% lifetime cost savings and 64% release to return to work for acute injuries and 29% lifetime cost savings for legacy catastrophic cases. For complex pain, stress the outstanding results that Paradigm achieves in helping very entrenched, complex cases get healthy, back to work, and off narcotics, resulting in 41% lifetime cost savings and 43% release to return to work rates.
Most case management companies are built to handle the bulk of standard medical or lost time claims, but Paradigm is a specialized company, managing only catastrophic and complex injuries. Paradigm has the infrastructure, historical data and expertise to deliver industry leading results on these most volatile and costly cases. Specifically, Paradigm outperforms the industry by 5x in getting catastrophically injured workers healthy and returned to work while saving payors 40% on lifetime medical costs. For complex pain cases, Paradigm achieves release to return to work rates of 43% for long-term, chronic pain cases and lifetime cost savings of 41%.
Founded in 1991, Paradigm Management Services, LLC, specializes providing comprehensive medical case management services for catastrophic and complex injuries such as traumatic brain injuries, spinal cord injuries, amputations, burns, and complex pain conditions. Paradigm’s 99% success rate for achieving or exceeding targeted goals allows them to stand behind their performance as the only company to guarantee medical outcomes for acute catastrophic cases.
Injured Worker and Family FAQs
Paradigm communicates routinely with the insurance company and/or employer and keeps them informed of important aspects of the care and recovery. This frequent communication ensures they understand the condition, progress and the medical importance of the care planned for recovery.
No. Paradigm’s services are paid for by the insurance company or employer. The insurance company and employer understand that specialized, expert case management can result in improved healthcare outcomes, so they pay for Paradigm’s services at no cost to the injured worker. When seriously injured workers are supported by Paradigm they have the opportunity to recover more fully and with fewer complications. The companies that hire Paradigm understand this value, knowing it can also reduce medical complications and their long term costs. Paradigm’s doctors, nurses and clinicians have the sole aim of ensuring quality medical care.
Yes. A Paradigm nurse case manager will present the injured worker a release of information form for signature that allows us to access medical data. Paradigm follows all applicable data and confidentiality requirements for personal health information (PHI). Paradigm maintains high standards of security as it relates to data we collect, including but not limited to health and medical data, personal information, demographic data and financial data. Paradigm’s technological systems restrict access on a “need to know” basis, requiring secure authorization and subject to regular audits. Access to all information is strictly managed with checks and balances built in to monitor use and exposure.
Yes, Paradigm’s nurse case managers are aware of the rules and regulations in jurisdictions within which they operate, and are workers’ compensation board certified in catastrophic management in states where statutorily required. Further, Paradigm complies with all applicable state and regulatory agency data reporting requirements. Paradigm’s compliance department routinely monitors changes to ensure adherence in each of these areas.
Yes, this can be supplied by the administrator or Paradigm, subject to any applicable state regulations and required releases.
No, quite the opposite. Paradigm’s focus is to work collaboratively with the injured worker’s physician to ensure that the necessary treatment is identified and effectively coordinated so the most optimal outcome may be reached.
To achieve the highest possible functional outcome, Paradigm helps injured workers and their families understand the complexity of the specific injury and the resources needed to return to a productive lifestyle. Paradigm nurse case managers and Medical Directors leverage their extensive knowledge of local resources, consulting specialist physicians, and leading national facilities and Centers of Excellence. In this way, the Paradigm Management Team can offer the most comprehensive recommendation to the injured worker, family and insurance carrier, focusing on the providers with the strongest track record for any specific injury. With this support, the injured worker is empowered to evaluate the options and make an informed decision.
As an independent company managing only complex and catastrophic injuries, Paradigm gives injured workers the benefit of specialized consulting physicians and other clinical professionals who provide coordination for optimal treatment. Our focus is always on the best interests of the injured workers and helping them progress toward the highest medical outcome achievement possible.
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