Nurse Case Manager: Friend or Foe?

The purpose of a nurse case manager and what to do if you are being treated poorly.

There are two types of nurse case managers. The nurse case manager who works from an office and handles all the communication by phone, e-mail, fax and regular mail, normally addressed as a telephonic case manager or TCM; and the nurse case manager who practices directly in the field, meeting in person with the injured individual and the medical provider(s), known as a field case manager or FCM.

Usually a nurse case manager will be assigned if any of the following happens during your work schedule: an accident where immediate hospitalization is required, amputation of limbs, second degree burns, electrocutions, concussions, immediate loss of hearing and vision impairment, heart attack or stroke on the job (if the claim is compensable), shoulder and muscle injuries, ankle sprains, back and neck injury claims, occupational skin and lung diseases such as asbestosis and pneumoconiosis, amongst other injuries that may require time off work.  

The job of a nurse case manager is to work with the patient directly in order to make the necessary arrangements for patient care, including the coordination of appointments between multiple doctors. The nurse case manager is a registered nurse employed by the insurance carrier. As a result, his/her job is to also keep the insurance carrier informed about ongoing treatment, as well as when the patient is medically cleared to return to work.  

But because insurance companies often want to reduce costs, they go to great lengths to try and influence case managers and medical treatment. There have been cases where nurse case managers have tried to push doctors into releasing an injured individual before they should actually be released. And they have also tried to convince physicians not to provide certain types of treatment due to the fear it would cost a large sum of money for the insurance company. Like everything else, there are some good and some bad case managers.

Since the insurance company pays the nurse case manager, it is important to make sure that any nurse case manager has your best interest at heart and is not just out to save the insurance company money. Make sure you know your legal rights. You should always pursue the recommendations of your doctor and don’t let the nurse case manager get in the way of you and your necessary medical treatment.

Medical Case Management Do’s and Don’ts

Some guidelines regarding nurse case managers that you should be informed of:

DO:
-Be understanding of all parties involved in the medical recovery process, especially the injured individual and their family.
-Include objectives and deadlines when creating the care plan, and allow for updates as needed.
-Decide if treatment is appropriate.
-Decide if funding for case management services is ensured before proceeding.
-Figure out what is required for a successful return to work, especially from employer’s needs.
-Be a clients advocate and supporter at all times, and provide key contribution and supervision on treatment services BE A LIAISON BETWEEN PARTIES.
-Use valid disability duration guidelines, and use them as GUIDELINES.
-Inform all parties, especially employer, whenever possible on the positive and money-saving aspects of return to work programs and procedures.
-Always obtain and maintain suitable releases of information prior to starting case management services.
-Understand that there are numerous players in the case management process, but that your main client should always be the injured individual.
-Always recognize your role clearly as a case manager to the hurt individual at the start of the relationship. 
DO NOT:
  -Give legal counsel at any time.
-Book IME appointments.
-Modify employee’s doctor appointments just to fit YOUR schedule.
-Refuse to give information vital to RTW success.
-Be responsible for disability by failing to address doctor orders, health concerns, or return-to-work issues in a timely manner.
-Become personally and/or emotionally attached to the client.
-Presume that you have an absolute right to attend all doctors’ appointments despite client wishes against it.
-Interfere with due process between the hurt individual and his/her employer.
-Commence cost services prior to obtaining carrier authorization.
-Provide legal guidance to the claims adjuster, or get involved in claims investigative or adversarial activities.

Seek legal help from an experienced workers compensation attorney

If a nurse case manager is interfering with your medical care or treating you badly, you need to seek lawyer help. You have the right to privacy in the examination room and to know what is being said behind your back.