In workers’ comp, most nurse case managers (NCM’s) are aligned with the insurer. They’re involved in coordinating, scheduling, and collecting data. While they have access to some medical data, you may have more control than you expect over appointments with clinicians and which records you share.
Your insurer may assign you a nurse case manager for workers’ comp claims. They will coordinate care for the insurer. They may be involved with injury recovery assistance and logistics, or the expected treatment path. However, they are not here for you. They are here for the insurer.
You can set boundaries with them regarding your medical treatment including stopping them from coming in the room during your doctor’s appointment. They have no legal right to be in the exam room with you and should never be allowed in. Limit your communication as much as possible.
If you feel rushed back to work or misunderstood, inform them that you would prefer to engage through your workers’ comp attorney if you have one. Doing this will reduce the risk of mistakes or misunderstandings.
When there is pressure to make any change you feel uncomfortable with, it may be time to contact Pearson Koutcher Law for a consultation from a workers’ compensation attorney.
Nurse case management involves communication between the insurer and claimant, to coordinate care.
They do not act as the treating clinician (the doctor making medical decisions). Instead, the scope of their power is limited to a few key areas.
During these processes, make sure you know what you should and should not say to your insurer’s doctor and the nurse case manager. We recommend consulting a legal expert opposed to speaking with a nurse case manager. Lawyers can communicate with the nurse case manager on your behalf and help you fulfill the healthcare coordination process safely.
Insurers typically use a nurse case manager at any time, but more often when a situation is particularly complex. Examples include:
An insurer may also use a nurse case manager to guide you toward a provider on their panel-provided list or to remind you of the limits of your care.
If a nurse case manager contacts you for any reason and you do not have a workers’ comp lawyer, you should take steps to protect yourself. First, communicate that your data releases should be as narrow as possible. It should cover only injury-related data and the time surrounding the accident.
Laws also include barring anyone not involved in treatment from entering private exam rooms when a patient requests.
If you are asked to meet the case manager in person and choose to attend, do not sign anything without having a workers’ compensation lawyer review it first.
If your case manager suggests that this may affect your case, rest assured that they cannot actually stop your care. At best, they can recommend that your case be reviewed. But, they will try to exert pressure on your doctor’s to release your back to work (even if you don’t feel ready to return safely).
If you feel uncomfortable at any point, clearly state a preference for written updates on your situation to ensure you have records. After this, you should forward all communications to a lawyer for advice. Workers’ compensation lawyers do not get paid until you do.
A nurse case manager cannot force you to change clinicians after 90 days. They can’t deny you care.
Several other limits exist in Pennsylvania, including:
Neither title is explicitly defined in Pennsylvania law, and as such, there is no difference in the eyes of the law.
As a colloquial term, however, care managers tend to be more hands-on with managing medical treatment. They take an active role in the patient’s care. Be aware that different insurers may use these labels differently.
You cannot prevent a nurse case manager from looking into your case, but you do not need to be the person who communicates with them. At Pearson Koutcher Law, we will speak with them for you.
Set HIPAA-based limits to their access to your records. Funnel all communication through a legal professional who can take the situation off your hands.
When you first receive a message from a nurse case manager for workers’ comp, you may be unsure of what to do. Prioritize your own safety and your compensation by setting boundaries.
If you feel pressured by the nurse case manager, contact Pearson Koutcher Law. We can discuss your case and begin protecting your rights. We focus on workers’ compensation in PA, with Spanish-speaking support available for those who need it.
Call the Workers’ Compensation Law Firm of Pearson Koutcher Law and book a free consultation before making any major decisions today.