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Nurse Case Managers: The Good, The Bad, The Ugly, and Your Rights as an Injured Worker

So you get hurt at work and not long after, you get a cheery letter from a “nurse case manager” or “case manager” or “rehab consultant,” happily telling you she will be accompanying you to all your doctor appointments, just to help you out with care. But she doesn’t work for the doctor, and she can’t prescribe any treatment.

Who is this person, and what does she do?

The intended purpose of nurse case managers is simple, but they can complicate your case. Nurse case managers:

  • Help you get proper care ASAP, and
  • Help the workers’ comp insurance company keep up with your treatment, including your symptoms and diagnosis.

Maybe you already caught the potential complication: all nurse case managers work for the insurance company. So you’ve got to be careful, and you’ve got to know your rights, especially if the nurse case manager turns out to be a bad apple who’s out to close your case cheaply. Mind you, many nurse case managers are genuinely concerned for your health and can really help you get good care.

So here’s the good, bad, and ugly on nurse case managers—plus a review of your most important rights.

The Good

Legally, the nurse case manager’s primary concern is supposed to be your recovery and return to work. For you, they are supposed to facilitate, coordinate, and manage your care. That means they should, most importantly:

  • Help you get appointments with the right specialists to treat your injuries.
  • Attend visits to report your symptoms, diagnosis, prognosis, and treatment recommendations to the insurance company, subject to your most important rights we discuss below.
  • Follow up with the insurance company to get approval for referrals to other providers.
  • Remind you of appointments.
  • Help you get transportation at the insurance company’s expense, if needed.

All this is good, but there’s some potential bad, too.

The Bad

Here’s the main thing: you’ve got to remember they work for the insurance company, which profits by limiting your treatment and settling cheaply in the end. That’s really bad only if you’ve been assigned a nurse case manager bent on helping the insurance company instead of you.

Many folks get uncomfortable over the fact nurse case managers can learn a lot about you without your consent. That includes:

  • Attending your doctor visits. No doubt this feels like a violation. But remember you’ve still got your most important rights we discuss below.
  • Discussing your private health information with your providers, including your medical history, diagnosis, injury cause, treatment, prognosis, work restrictions, and disability from the injury.

When a nurse case manager abuses these privileges, it leads to…

The Ugly

Rarely, we get a nurse case manager who’s just an advocate for the insurance company. Warning signs include:

  • Pushing doctors to release you.
  • Questioning the doctor about your need for treatment.
  • Questioning whether the diagnosis is legitimate.
  • Pressing the doctor on whether you really need work restrictions.
  • Pushing you to admit you’re not hurt that bad.
  • Leaving out important parts of doctor visits in her notes—or twisting words spoken by you or the doctor.

If that’s the case, you need an experienced workers’ compensation attorney immediately to help protect you. Because you’ve basically got an insurance executive tagging along at your medical visits, looking to shortchange you—medically and financially.

But you’ve still got rights, and they are important. You need to know them.

Your Two Most Important Rights

The most vital right is that you can choose to be examined in private by the doctor. If so, the nurse case manager can’t come in for that.

We’ve found that in most cases, that’s the best way to do it. Even if you’ve got an injury that’s not embarrassing, like a broken arm, it’s just easier on you—and maybe even the doctor—to do the exam without an audience. Doctor visits are not a spectator sport.

Plus being alone with the doctor makes it easier on lots of folks to share their symptoms freely. If you injury isn’t embarrassing, sometimes the effects of it can be. No tough factory worker wants to admit their shoulder keeps them from picking up a grocery bag. Having those conversations are hard enough when it’s just with a doctor you feel is on your side. Doing it with a nurse case manager there can just make some people clam up, leaving out important symptoms that can make a real difference in the doctor’s diagnosis, treatment—and the outcome of their case.

So it’s better to do it in private, because if you don’t paint the doctor an honest and thorough picture of what you’re going through, it can lead to inaccurate medical conclusions that can wreck your case.

Your second most important right: You have the right to be present when the doctor and nurse case manager discuss your case. Listen carefully. If anything’s missed or misstated, pipe up! This is your case, and your body, and you’ve got to help the doctor help you.

Get Guidance on This and All Your Questions

Workers’ compensation is designed to help workers, but many find it complicated, confusing, and even a little intimidating. Don’t just let your case happen to you. Take a little control back!

One of the unspoken benefits of having an experienced workers’ comp lawyer on your side is that you’ve got a guide to help you through the system—a guide who knows it just as well as everyone who’s against you on the other side. The nurse case manager’s got the insurance company’s back, just like the adjuster, so you need a professional who’s got yours.

If you’ve got any other questions, feel free to start a live chat from our website, where you’ll get your questions answered by a skilled workers’ compensation attorney.

 

Rob Usry
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Rob is a South Carolina personal injury and criminal defense lawyer.

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