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the nurse case manager in workers' comp

Beware of the Nurse Case Manager in Workers’ Comp

Episode 26: Louisville workers’ compensation attorney Scott Scheynost explains how an injured worker might be getting mislead by a nurse case manager.  We all want to trust our medical providers.  Insurance companies know this and sometimes take advantage of this fact.  That’s why they might use nurse case managers to influence decisions made between you and your doctor.  If you’ve been injured on the job, beware of the nurse case manager in workers’ comp claims.

DISCLAIMER:  It’s important to state that Scott values nurses and the often, unappreciated work they do in hospitals, assisted living facilities, nursing homes, clinics and other facilities.  This episode isn’t focused on nurses who work with patients to provide healthcare.  However, a nurse case manager plays a dramatically different roll.  They are not actually patient advocates.  In many case, they actually advocate on behalf of the insurance companies who are paying them.  As you’re about to learn, they may actually work against your best interest when it comes to your medical treatment.

Scott Scheynost discusses the role of a nurse case manager in workers' comp

What Is a Nurse Case Manager?

If you’ve been injured and are seeking medical treatment, you may suddenly realize a nurse case manager has been assigned to you.  Unfortunately, this person not here for the reason you might assume. 

The insurance company usually hires or contracts with a person to serve as your nurse case manager.  Yes, they are nurses, but their role here is to handle your case.  It has to do with the cost of your case, both in the immediate and long-term.  Their objective is to save the insurance company money.  They aren’t there to be your nurse.

Often, they may be in the room with you and your doctor during medical treatment, exams or consultations.  They will try to influence decisions involving tests, procedures or other treatment options that usually cost the insurance company less money.  Remember, if you’ve been hurt at work, your workers’ compensation benefits are being paid by the workers’ comp carrier (i.e. the insurance company).  They have a vested interest in minimizing the expenses related to your claim.

Now, to be clear, Scott has seen some of these nurse case managers try to be helpful to the injured worker, but the vast majority are there on behalf of the insurance company.  They are not there to provide treatment to the patient.  This creates an adverse interest to the person who is injured.

Ways a Nurse Case Manager Can Save the Insurance Company Money

Understand, this is the primary objective.  It’s why you need to beware of the nurse case manager in workers’ comp.  Here are a few ways they may try to reduce expenses, rather than focusing on what’s best for you:

  • Limiting Your Medical Treatment
  • Influence You and the Doctor about the Type of Treatment
  • Influence You and the Doctor about Where You Get Treatment
  • Help Select Other Doctors Who Might be more Favorable to the Insurance Company
  • Influence Decisions about How Long You Receive Treatment vs. Returning to Work

In Episode 6, Scott explained one of the most important rights you have under Kentucky workers’ compensation law.  You get to choose your doctor.  The company or the nurse case manager may attempt to try to steer you to a specific doctor for treatment.  There’s a reason they’re doing this.  It’s often because they know that particular doctor may have a history of making treatment decisions that tend to benefit the insurance company because they are less expensive, not necessarily because they are as effective.

What You Might Not Know About the Nurse Case Manager

  • They Aren’t a Nurse Who’s There to Treat You
  • They Are Hired by the Insurance Company to Contain Medical Costs
  • You Don’t Have to Talk to the Nurse Case Manger
  • You Don’t Have to Let the Nurse Case Manger into the Doctor’s Office with You
  • The Nurse Case Manager Is Not Qualified to Tell You What Your Claim is Worth
  • They Nurse Case Manager Knows How to Influence Decisions about Your Care

What If a Nurse Case Manager Steers You to Doctor Who Assigns Lower Impairment Ratings?

A doctor will eventually assign you an impairment rating, usually after you’ve had an independent medical exam (IME).  The higher your impairment rating, the more benefits you may receive.  On the flip side, if a doctor assigns a lower impairment rating, you may ultimately receive less money as part of your workers’ compensation benefits. 

The impairment ratings can be extremely subjective.  Multiple doctors could see the same patient and each determine different ratings.  So, if the nurse case manager knows certain doctors are more likely to assign a lower impairment rating, that could ultimately save the insurance company a lot of money, especially if the benefits are going to be paid for a number of years.

Can a Nurse Case Manager Influence Your Work Restrictions?

Yes.  Similar to impairment ratings, different doctors may assign different types of work restrictions.  Those restrictions may limit the type of work you can do, if you are able to return to work.  Generally, the more restrictions you get, the higher the value of your workers’ comp claim.  So again, if the nurse case manager can steer you toward a specific doctor or influence the restrictions that particular doctor assigns, it can reduce your benefits and save the insurance company money.

Start with Your Family Doctor for Your Workplace Injury

Scott recommends contacting your family doctor, if you are injured on the job.  The family doctor is focused on you, not the company and/or the insurance company.  They want to make you better.  They most often have your best interest at heart.

Your family doctor may refer you to certain specialists, but it’s because they are comfortable with that doctor’s experience and reputation.  It’s not because they want to save the insurance carrier some money.

Dealing with the Nurse Case Manager

As Scott has stated, you need to beware of the nurse case manager in workers’ comp claims.  However, some people aren’t sure what to do or if they are allowed to do it.  Scott recommends you think of the nurse case manager as an insurance adjuster.  Would you want that adjuster present in the exam room with you and your doctor? 

You have the right to ask them not to be in the room during your consultation or exam.  This is your time with the doctor.  They may have an authorization to speak with the doctor about your case, but they are not necessarily authorized to participate in your doctor’s visit. 

The doctor may decide he/she would like the nurse case manager to be in the room.  That’s his/her right.  However, this should be a red flag.  Is the doctor willing to be influenced for some undisclosed reason?  If so, does this doctor actually have your best interest in mind?  It may be time to find a different healthcare provider.

Can a Nurse Case Manager Contact Me Directly?

Yes.  They can call you, but Scott recommends you have them speak with your attorney, instead.  Remember he/she is often trying to influence decisions being made about your treatment (because of the costs).

Now, if this is a catastrophic injury, the situation may be complicated enough that the nurse case manager should be involved, to an extent.  Nonetheless, Scott emphasizes that the vast majority of the workplace injuries don’t fall into that category.

Another reason Scott suggests you beware of the nurse case manager is because he/she may begin making statements to you about the law or where your case is going.  This person is not an attorney and they are definitely not your attorney.  This may be a manipulation tactic designed to, again, influence your decisions related to the treatment of your workplace injury.

Other Tell-Tale Signs to Consider

It’s important to understand that not every workers’ compensation claim results in having a nurse case manager assigned to it.  So why does it happen?  Your case might be big enough for the insurance company to justify taking on the expense of a nurse case manager.  They are betting he/she will save more medical expenses than what it costs them to pay them.

If you haven’t already spoken to an experienced workers’ compensation attorney by the time you find that a nurse case manager is involved, you need to make some phone calls.  Your claim may be bigger than you realize.  Remember, the insurance company is anticipating a return on their investment.

Scott Scheynost Handles Workers’ Comp Cases Throughout Kentucky

Scott can handle workers’ compensation claims across the state of Kentucky.  In some cases, you may not reside in Kentucky, but maybe your job has a connection to Kentucky.  There are certain circumstances in which Scott may be able to represent you with your workers’ comp claim.

It’s important to work with an experienced Louisville workers’ comp attorney to protect your rights and the benefits you deserve.

It Cost You Nothing to Speak with Scott

Contact Scott Scheynost at (502) 937-5287.  This podcast is meant to provide information and is not legal advice.  Scott’s principal office is located at 7619 Dixie Highway, Louisville, KY 40258.  Co-host Jim Ray is a non-attorney spokesperson.  This is an advertisement.