Help With Pressure From WC Case Manager

[redlotus]

Hi All
I'm brand new to this forum, and looking for a little advice on dealing with a difficult case manager. A little history - I work in the mental health field with behaviorally challenged children. Three years ago I was kicked in the right knee by an angry child. There was damage done to my articular cartliage (the coating on the end of my thighbone). Since cartilage does not heal, the damage continued to increase over time and I began to have more severe problems with my knee (pain, swelling, mechanical issues). Luckily I had documented the initial injury, and had little trouble getting WC to pay for a visit to the doctor, which led to a referral to an orthapedic surgeon. Long story short, I had three arthroscopic knee surgeries over the next year and a half. These were to clean out bits of cartilage that had chipped off the damaged site and were causing more damage inside the joint. However, they did not fix the original damage. Finally my surgeon told me he couldn't do any more for me and referred me to a specialist.

Up until this point WC had not given me much grief. I could tell they were not happy about having to pay for three surgeries and time missed from work, but I wasn't too happy about it either, and regardless they did what I needed.

Once I got in to see the specialist, he determined that I was an ideal canidate for an autologous chondrocyte implantation - a rather high-tech (expensive!) and involved procedure, but basically the only ting that would restore my knee to something close to normal. This is where the trouble starts.

It took more than eight months for WC to approve the initial surgery (it's a two-part deal). I was on the phone several times a week, being the squeaky wheel. My WC case manager was CLUELESS, and I basically had to be the middle woman between him and my doc's office since he would not request the needed info on his own. Finally they approved it, and he assured me that the whole deal was approved. I had the initial surgery, and then was told that I had to wait to get the second half approved, despite having been told it was already a done deal.

Finally this CM must have decided that I was too much of a pain in his keister, because without telling me he transferred my case to a new manager. She is the one I am dealing with now.

After much grief, I had the big surgery. This procedure has a LONG rehab. I was on crutches for more than five months, all the muscles in my leg atrophied, and it was a lot of PT to get walking again. Plus I had to have another scope (that makes 6 surgeries!) to take out scar tissue.

Because of the work I do (very physical, high risk, etc) my doc warned me, and my WC CM, that he would not sign off on me going back to work until between 9-12 months. If I were to get kicked again, hit, or otherwise roughed up before then, I would risk having to do the whole thing over again.

It's been about 8 months now, and my WC case manager is starting to REALLY put the pressure on me, and my doc, to have me go back to work. I am scheduled for an MRI in the fall, and if that is clear I am ok to work. I have told her this, more than once.

Last week, my WC check did not arrive in the mail, and I got a message from my CM asking me to call her. I returned her call, left a message, and also mentioned that I had not recived my check and asked her to please send it asap, as I have bills overdue.

Instead of calling me back, she called my doc's office "on my behalf" and was very rude to them, telling them that they "needed" to schedule my follow-up MRI "THIS WEEK." She is starting to really pressure me to go back to work, despite the fact that I do not have medical clearance to do so. Now she is pressuring my doc to move up his schedule and rush things along in order to get me back to work sooner.

I still do not have my latest check, either.

What can I do about this? I am worried that she is going to cut off my WC pay, thereby totally wrecking the little financial stability I have. And I feel that she had no right to withold my check, seeing as how it covered the previous week - I week I had already missed due to my injury. Because I was not paid money owed to me, I am incurring fines on my late bills and in danger of having my gas shut off.

Advice? Please?

Also, sorry for the LONG rambling post - it's a lot of ground to cover!

thanks in advance,
Redlotus

[Hoosier_Daddy]

I wish I had advice for you. My employeer paid for MRI's and Xrays for my knee and gave me a sit down job for 5 weeks. then the doctor they sent me to said I needed surgery. They then told me to go on a personal leave. Well that was April of 2006. I have had 6 surgeries since, and need a new 1 asap. I have had a cadaver bone inplanted into my knee. We have had to pay for everything. It is awful. I have applied for SSDI as I can't do close to any kind of real work. I did get my court date today. March 24th. So I know how hard it is for you. I do not see how thwy can just shut you off for no reason however.

[Bad Boy Bad Boy]

I know of the ACI surgery, or as some say (Cartilage Re-Growth) system. In fact I know the doctor that invented this for sports patients.

Saddly to say, everyone I knew that had this done, did return to work, and waited for the next surgery to smooth out the (Cartilage Implants, or pellets). Many were walking the very next day after that also.

Since I know of this, surely your Case Manager knows of it. And then is using it against you to get you back to work.

[jayne]

all heck she can say the check is in the mail these tastics are normal......call and let her know you are willing to do what you can to get back to work but when the Doc feels its safe, let her know you want your checks on time or you will call her boss and if not taken care of you will have no choice but to put it all in the hands of a lawyer...its a normal stalling she wants you to know you are in her hands.....let her know you can get a lawyer to slap her hands if she doesnt get your checks to you on time once in the hands of a lawyer and the checks are late they get a fine that goes to you

[1171]

you need a lawyer. once you do all communication goes thru them. doctors deal with insurers all the time and should be somewhat immune to their pressure.
you may wish to discuss the situation with your employer. possibly they can intervene with the carrier and if not you can explain the need for legal representation.

[redlotus]

Thanks for the replies.

Bad Boy Bad Boy, my surgeon said that I had one of the largest areas of damage he had repaired. I had over 2 sq inches of damage on my medial femoral condyle alone, and then two large, bone-depth holes on the back of my kneecap. There are different rehabs for differnt graft sites, and I also had a tibial tubercle osteotomy, which involved cutting out a part of my shinbone and relocating it/screwing it back into place. Because of the dual graft sites, it was a more complicated rehab. Also, the follow-up surgery I had was not just to smooth out a graft, but to cut out a huge scar adhesion, so I had a drain in my leg for a week and a different rehab. The real issue is the nature of my work, which is very physical. There is no "light duty". I work in direct care with severely behaviorally challenged kids, who are often violent and lash out physically. My boss could try to say I could do light duty (no restraining, no lifting, etc) but there is no way to guarentee that I would not get hurt by one of the kids, esp if they knew that I was already injured - they would target my existing injury.


As an update, I had a conversation with my adjuster this afternoon. I am waiting for an apt for a final MRI that will clear me to go back to work. She left me a message saying that she was "holding onto" my two most recent checks (one of which should have been mailed a week ago) until I gave her a definate apt time. I called back and explained that my doc was submitting the prior authorization but could not give me an exact date until that was approved. My adjuster stated that I "needed to call every day" until I got an apt. When I stated that I had been told they would call me with the apt (and they have done so in the past) she said, "well, then I'm going to call them every day, and I'm going to schedule appointments FOR you, seeing as you apparently can't do so." I told her that she certainly did not need to make apts on my behalf, and that I felt she had no right to make those decisions for me. She then stated that she would send out the two checks, but that she was going to again "hold onto" my next check until I called with an apt. I said that I thought it was questionable, legal-wise, for her to withhold money for work I have already missed, and she stated "Well, then, I'll just go ahead and terminate your benefits, and then I will have the right." The "conversation" (more like her literally yelling at me) ended with me telling her that I was getting a lawyer, and she could talk to him/her from that point on.

I called her direct supervisor and complained, and he is supposedly going to call me tomorrow after he speaks with her. When I asked him if it were within her rights to hold my checks like she is, he would not give me a direct answer which leads me to beleive that she does NOT have the right. I also called a family friend who is a lawyer, and though he does not generally do WC he is going to talk with me and give me what advise he can. In the meantime, can anyone reccomend a good WC lawyer in Mass?

This sucks...

Also, Hoosier_Daddy, I'm sorry about your situation - that sounds awful. Luckily my employer has been great, it's the WC folk that are being a pain. My doc and his staff are also on my side, and offering to help any way they can.

[oblivyous]

1171 is telling you that you need a lawyer now. Her advice is always right on. Case managers are paid bonus bucks for every claim denied . Your lawyer can deal with her. You wont have to. Case managers prey on injured workers who dont have lawyers.

[Bummer Knees]

Welcome to the forum.

If you will look ath the top of this page you will see comp yellow pages.

Go to injured worker attorneys and click on this, it sould take you to your state's list of attorneys.

[Steph1966]

redlotus Wrote:Hi All
I'm brand new to this forum, and looking for a little advice on dealing with a difficult case manager. A little history - I work in the mental health field with behaviorally challenged children. Three years ago I was kicked in the right knee by an angry child. There was damage done to my articular cartliage (the coating on the end of my thighbone). Since cartilage does not heal, the damage continued to increase over time and I began to have more severe problems with my knee (pain, swelling, mechanical issues). Luckily I had documented the initial injury, and had little trouble getting WC to pay for a visit to the doctor, which led to a referral to an orthapedic surgeon. Long story short, I had three arthroscopic knee surgeries over the next year and a half. These were to clean out bits of cartilage that had chipped off the damaged site and were causing more damage inside the joint. However, they did not fix the original damage. Finally my surgeon told me he couldn't do any more for me and referred me to a specialist.

Up until this point WC had not given me much grief. I could tell they were not happy about having to pay for three surgeries and time missed from work, but I wasn't too happy about it either, and regardless they did what I needed.

Once I got in to see the specialist, he determined that I was an ideal canidate for an autologous chondrocyte implantation - a rather high-tech (expensive!) and involved procedure, but basically the only ting that would restore my knee to something close to normal. This is where the trouble starts.

It took more than eight months for WC to approve the initial surgery (it's a two-part deal). I was on the phone several times a week, being the squeaky wheel. My WC case manager was CLUELESS, and I basically had to be the middle woman between him and my doc's office since he would not request the needed info on his own. Finally they approved it, and he assured me that the whole deal was approved. I had the initial surgery, and then was told that I had to wait to get the second half approved, despite having been told it was already a done deal.

Finally this CM must have decided that I was too much of a pain in his keister, because without telling me he transferred my case to a new manager. She is the one I am dealing with now.

After much grief, I had the big surgery. This procedure has a LONG rehab. I was on crutches for more than five months, all the muscles in my leg atrophied, and it was a lot of PT to get walking again. Plus I had to have another scope (that makes 6 surgeries!) to take out scar tissue.

Because of the work I do (very physical, high risk, etc) my doc warned me, and my WC CM, that he would not sign off on me going back to work until between 9-12 months. If I were to get kicked again, hit, or otherwise roughed up before then, I would risk having to do the whole thing over again.

It's been about 8 months now, and my WC case manager is starting to REALLY put the pressure on me, and my doc, to have me go back to work. I am scheduled for an MRI in the fall, and if that is clear I am ok to work. I have told her this, more than once.

Last week, my WC check did not arrive in the mail, and I got a message from my CM asking me to call her. I returned her call, left a message, and also mentioned that I had not recived my check and asked her to please send it asap, as I have bills overdue.

Instead of calling me back, she called my doc's office "on my behalf" and was very rude to them, telling them that they "needed" to schedule my follow-up MRI "THIS WEEK." She is starting to really pressure me to go back to work, despite the fact that I do not have medical clearance to do so. Now she is pressuring my doc to move up his schedule and rush things along in order to get me back to work sooner.

I still do not have my latest check, either.

What can I do about this? I am worried that she is going to cut off my WC pay, thereby totally wrecking the little financial stability I have. And I feel that she had no right to withold my check, seeing as how it covered the previous week - I week I had already missed due to my injury. Because I was not paid money owed to me, I am incurring fines on my late bills and in danger of having my gas shut off.

Advice? Please?

Also, sorry for the LONG rambling post - it's a lot of ground to cover!

thanks in advance,
Redlotus

[Steph1966]

Wow, you really are scaring me with your case. I am scheduled April 29th to have the same surgery and also have my kneecap moved back into place. I have already lost my position at the bank where I used to work. I'm thinking it might be a good idea to contact an attorney immediately after surgery to avoid issues with case workers, lack of checks etc... My understanding is the recovery for this procedure is about a year and a half and I will not have anyone force me to recover faster than my body is ready. I was also told that this may bet me back to about a seven on a scale of 1-10. Do not let anybody push you into work before you're ready. This will cause more damage to your knee than there already is! So frustrating. I hope you have a comfortable outcome after the healing time has passed.