Keep Calm; Call a Nurse: Practical Tips for Using Nurse Case Managers
By: Mallory E. Lidaka
Medical case management is a large part of handling workers’ compensation claims. The use of Nurse Case Managers is one of many resources that can assist with the positive progression of a claim. The main goal of Nurse Case Managers is to assist with the planning and coordination of health care services in an effort to assist an injured worker to be restored as nearly as possible to the worker's pre-injury level of physical function. 11 NCAC 23C .0103(2). Benefits a Nurse Case Manager can provide include (a) case assessment, (b) development, implementation, and coordination of a care plan, (c) evaluation of treatment results, (d) planning for community re-entry/return to work, and (e) referrals for vocational case services. 11 NCAC 23C .0103(2)(a)-(e).
Nurse Case Managers are governed by the North Carolina Industrial Commission’s Rules for Utilization of Rehabilitation Professionals in Workers’ Compensation Claims. These Rules are found in Subchapter 23C of the North Carolina Industrial Commission Rules. A full version of the Rehabilitation Professionals Rules can be found HERE. These Rules define the nature, extent, and boundaries of a Nurse Case Manager’s role in assisting with the medical case management of workers’ compensation claims.
We generally recommend involving Nurse Case Managers to assist with coordination of medical appointments, obtaining medical records, and keeping the parties up to date as to the medical and employment status of the injured worker’s claim. Nurse Case Managers can also be very helpful in recommending physicians, including specialists and doctors, to perform Independent Medical Examinations or Second Opinion Evaluations. Nurse Case Managers can further assist with clarifying an injured worker’s return to work options with the treating physician(s) and can be very helpful in assisting with obtaining responses from a treating physician to medical case management questions. Nurse Case Managers simply serve as another resource to adjusters to ensure their claims are being handled as efficiently as possible.
While the Rehabilitation Rules allow Nurse Case Managers leeway in their involvement in workers’ compensation claims, such involvement is not without limitation. A common misconception is that because the carrier provides compensation to the Nurse Case Manager for their services, the Nurse Case Manager “works for” the carrier or is an “agent” of the defendants. To the contrary, the Rehabilitation Rules require that the Nurse Case Manager remain neutral, serving the interests of both parties equally with the ultimate goal of assisting the injured worker to be restored to pre-injury status. As a result, communications with the Nurse Case Manager must be shared with both parties. We therefore recommend that neither carriers nor their insureds share privileged strategy communications, including those with the defendants’ legal counsel, with the Nurse Case Manager. If such strategy communications are shared with the Nurse Case Manager, although privileged, the Nurse Case Manager technically has an obligation to share those communications with the injured worker and their legal counsel. This would of course negatively impact the proper handling of a claim. Additionally, carriers must still be cautious of ex parte communications even if a Nurse Case Manager is involved. The sharing of medical information and discussion of an injured workers’ medical case management plan with physicians must remain in compliance not only with the Rehabilitation Rules, which set forth in great detail the manner in which Nurse Case Managers may properly communicate with a treating physician, but likewise in compliance with other portions of the Workers’ Compensation Act related to same. Accordingly, while Nurse Case Managers can provide great benefit to the handling of a claim, we recommend carriers familiarize themselves with the North Carolina Rehabilitation Rules before and during the retention of a Nurse Case Manager in their claims.
PRACTICAL TIPS IN USING NURSE CASE MANAGERS
Use them! Nurse Case Managers provide many benefits to ensuring the medical case management of an injured worker’s claim is handled properly and efficiently.
Take advantage of the Nurse Case Manager’s ability to more easily obtain medical case management information that carriers may otherwise have difficulty obtaining.
Do not forget that a Nurse Case Manager is required to serve as a neutral party – if you as the carrier are limited in obtaining certain information, communicating with physicians, etc. pursuant to the Industrial Commission Rules or Workers’ Compensation Act, the Nurse Case Manager may likewise be limited in the same manner. Always check the Rehabilitation Rules in North Carolina to ensure that the tasks you are seeking from the Nurse Case Manager are allowable as Nurse Case Managers’ roles vary from state to state.
If you have any questions about the benefits a Nurse Case Manager can offer in a claim or how you can most efficiently use Nurse Case Managers to move a claim forward, please do not hesitate to call any one of our experienced workers’ compensation attorneys at Lewis & Roberts.