When to Use a Nurse Case Manager in Your Claim

Nurse case managers play an important role in keeping excessive workers’ compensation costs in check. While having a nurse cade management program within the claims process can drive down costs, it is important to remember that one should not be used in every case. Using a nurse case manager in the right cases is paramount to running an effective and efficient program.

It Starts with Buy-in From All Parties

Many jurisdictions do not require the use of a nurse case manager in the claims process. The result is the injured employee can object to the use of one. Given these constraints, it is important for the nurse case manager to work ethically and honestly. Steps can be taken to establish rapport can include:

• Acting with empathy toward the employee;

• Establishing trust; and

• Open and honest communications with all parties, and interested stakeholders.

Setting the right tone from the onset will help the nurse case manager be the most effective.

Using Nurse Case Managers in the Right Cases

Not every case is right for using a nurse case manager. Using a nurse case manager in all cases will increase program costs. It is important to evaluate a claim before assigning a nurse case manager, and consider using one in the following instances only:

• Wage loss claims: Unlike “medical only” claims, instances that involve a wage loss tend to cost more in the long run. The added issue also adds to the complexity of the claim. When an employee is off work, they are facing what can be a difficult return to work issues. A nurse case manager can serve as a conduit and help coordinate the many complex issues associated with these claims. This can include understanding restrictions imposed by the treating doctor, assessing the employee’s transferable job skills, and coming up with creative ideas when preparing a written job offer.

• Any surgical claims: Surgery presents an interesting issue for everyone involved in a workers’ compensation claim. This includes the myriad of issues in terms of whether an independent medical examination may be necessary to assess the treating doctor’s recommendations, prior authorization issues associated with surgery and the claims process, post-surgical medical care, restrictions on activity, and communication with the employer regarding return to work. A nurse case manager can understand these issues and help coordinate the process.

• Malingering employee: An employee in this situation can be identified by a number of different behaviors. This can include someone who is doctor shopping (eg - seeking second opinions on many issues), non-cooperation with the treating doctor regarding future care, or a treating doctor who continues to provide restrictions on the employee’s activity without sufficient objective medical evidence. When confronted with these troublesome issues, a nurse case manager can intervene in the manner, coordinate with the parties and their competing positions, and find common ground. They can also make recommendations to the assigned claim handler regarding the possible need for an independent medical examination or independent vocational evaluation. 

• Attendance Issues at Medical Appointments: This can be one of the most frustrating issues for members of the claim management team. In many instances, there is no ill will on the part of the employee – there are simply structural barriers that prevent the employee from consistently attending their medical appointments. A nurse case manager is uniquely positioned to help identify these barriers in terms of ensuring the employee complies. This can include sending constant reminders regarding appointments or arraigning for transportation to and from all medical appointments.

Nurse case managers can be used in an effective manner to overcome common barriers to resolving workers’ compensation issues. When employed in the proper manner, they can be an effective agent to get troublesome claims back on track. Now is the time for claim management teams to review your files, and ensure you are using nurse case managers in the correct instances.

Conclusions

Nurse case managers play an important role in reducing workers’ compensation program costs. They should not be used in every instance. When used in the right instances – cases involving wage lose, surgery has been recommended, the malingering employee, or a non-cooperative treating doctor – they can be used to get cases pointed in the right direction. The result is better outcomes, and getting claims positioned for settlement.

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