Nurses are the unsung heroes of the medical profession.
They offer compassion, healing, advice, and education when we need it most.
But the nurse who holds your hand as you get wheeled into the operating room or the one who administers an IV when you're ill isn't the same as a nurse case manager who works for a workers' compensation insurance company.
What is a nurse case manager?
A nurse case manager works for the insurance company to serve as a point of contact to assist you in receiving the care you need to return to work quickly. They also keep the insurance adjusters updated on what your diagnoses are, what treatments you need, and when you can get back to work.
This is a good thing, right?
Sort of.
The nurse's job is to assist in getting what you need for a full recovery and return to work. The sooner you go back to work, the less the insurance company needs to pay in benefits, and the better it is for your employer, too.
But sometimes, the nurse case manager is more concerned about dollars and cents than they are about your medical care, and that's when it's a problem.
Like in any industry, there are individuals who are great at what they do and serve all interests in an honest and professional way. But there are also those who strive to save the insurance companies money because it makes them look good, and that can compromise your quality of care.
Below, we'll talk about the pros and cons of having a nurse case manager oversee your treatment, and what to do to protect your rights.
Are there benefits to having a nurse case manager?
In some situations, a nurse case manager can be helpful. The theory behind a model of care that puts a primary care provider (PCP) at the helm of your medical treatment is so your primary doctor will manage your treatment, coordinate specialists, and see you as a whole person — not just through the eyes of the specialist who might only be treating one body part, system, or illness.
But if your injury or illness is work-related, part of the nurse case manager's role is to handle the logistics of coordinated care.
A nurse case manager might:
- Help you make appointments with specialists for the work-related injury or illness.
- Work with the insurance company to get approval for referrals, diagnostic testing, and procedures.
- Help you coordinate transportation (covered by workers' compensation benefits) to medical appointments.
- Obtain information and documents for processing your claim.
- Develop a back-to-work plan.
Some of these services can be useful, especially if your injury has left you with a disability that prevents you from driving or if you're unable to schedule your appointments.
Protecting your rights with a nurse case manager
The Georgia State Board of Workers' Compensation made some recent changes that focus on case management. For instance, a nurse case manager might ask to attend your doctor visits with you.
It used to be the law in Georgia that every workers' compensation claim would have a case manager. Today, it's only mandatory for a case involving a catastrophic injury.
However, in a non-catastrophic case, you might be assigned a medical case manager, but that person may NOT attend your doctor's appointment without your written consent.
You have a right to be examined by your doctor in private.
Even if the nurse case manager has a level of medical expertise, the doctor doesn't need them there and neither do you. Your doctor will likely be more comfortable performing an exam or treatment on their own, or with their own office staff in the room.
You also have a right to doctor-patient privilege, which means that certain things you share with your physician cannot be shared with anyone else without your permission. You can and should tell your doctor exactly what symptoms, pains, or effects you're experiencing — the doctor can only give you the medical treatment you need if you tell them truthfully what's going on.
Why would the nurse case manager want to be present with the doctor?
One role of a nurse case manager is to help you get the appointments and referrals you need. But it's not out of the goodness of their hearts.
It's because the real function of a nurse case manager is to streamline processes and treatments in a way that saves the insurance company money by getting you back to work quickly. That way, the insurance company spends the least possible amount on treatment as possible.
4 requirements for nurse case managers in Georgia
- You or your lawyer must consent to a nurse case manager to work with you.
- You must provide written consent for a nurse case manager to attend your doctor's appointments.
- If you do provide consent, the nurse case manager must advise you that you have the right to withdraw that consent at any time.
- The insurance company may hire a nurse case manager who contacts your doctor without your consent to assess, plan, implement, and evaluate options and treatments.
What might a nurse case manager do to save costs for the insurance company?
- Encourage a doctor to release you from the hospital or terminate care too soon
- Question the doctor's decisions or opinions about your treatment
- Question the legitimacy of a diagnosis
- Question the doctor about whether you really need work restrictions
- Pressure you to minimize how injured you are or your level of pain
- Make reports to the insurance company that omit or misrepresent parts of your doctor's visit
Choosing a Georgia workers' compensation-approved physician
Georgia laws allow your employer and its workers' compensation insurance company to determine which doctors are acceptable.
Each employer must provide a “posted panel,” which is a list of approved treating physicians. If you suffer a work-related injury, you may seek treatment from any physician on the panel. That physician may make referrals to other physicians if you need testing, therapy, surgery, or other services.
5 requirements for a panel of physicians in Georgia
- A panel must include at least 6 physicians or practice groups that are not affiliated with each other. There can't be more than 2 industrial clinics.
- At least 1 doctor must be an orthopedic physician.
- Your employer might have a “conformed panel of physicians,” which includes a minimum of 10 doctors, with at least 1 general surgeon and 1 chiropractor.
- If your employer is part of a workers' compensation managed care organization (MCO) that's certified by the state Board, it might not have a panel. In that case, you may see a provider within the MCO, and there will be a 24-hour toll-free number that you can call for medical treatment.
- You may make switch to a different physician within the panel once. If you would like to switch a second time, you need to either have consent from your employer or the insurer, or you need to file a petition with the workers' compensation board.
When to consult a Georgia workers' compensation lawyer
If your work-related injury is minor, recovery is fast, and you're back to work quickly, you might not need a lawyer.
But what if it's more complicated?
You might have a lot of people giving you a lot of information — everyone from your employer's HR department to the insurance company to doctors. These individuals will give their opinions on what you need and when you can return to work (or if you can return to work at all).
But who's really on your side?
It's important to recognize what each interested party wants from your recovery:
| Party | Desired outcome |
|---|---|
| Employer | Wants one of 2 things:
Your employer also doesn't want your job vacant while you're out because that, too, translates into lost productivity. Turnover costs employers money. |
| Insurance company | Wants to close your claim by spending the least amount of money on your recovery as legally possible. |
| Doctor | Wants to provide treatment that meets your medical needs. |
| Nurse case manager | Wants to please their boss, just like you aim to please yours. Their boss is the insurance company, so they're motivated to get you back to work quickly, while spending as little of the insurance company's money as possible. |
| YOU | Want to recover quickly and return to work, or have your claim covered so that you can take time for your disability or recovery but still have your financial needs met. |
In addition to yourself, there's one other party that has your best interests in mind who isn't listed above: your lawyer.
As a Georgia lawyer who has handled hundreds of workers' compensation cases in my decades of practice, and I've seen first-hand how nurse case managers and insurers try to manipulate doctors and injured workers just like you.
But it stops here.
It's important to hire a workers' compensation lawyer who'll fight their hardest to get what you need — whether it's medical treatment or weekly benefits.
There's a lot to be considered in a workers' compensation case. Sometimes, it's how injured you really are; other times, there could be questions about whether it's even a work-related injury in the first place.
Whatever the questions are in your case, you deserve to get them answered and get the results you need for recovery.
angela says
this post was right on the money. I recently was given a case manager to help with my doctor needs . when she attented a meeting with some of the staff. After that I was released from the doctors office without ant warning . I believe these people do not care about patients at all. Be wise like the article says don’t trust case managers from your insurance.