Theoretically, the job of a workers' compensation nurse case manager (NCM) is to assist a claimant with medical treatment and recovery. If you've sustained a work-related injury or illness, you're generally entitled to file a claim for workers' comp benefits, which provide no-fault coverage of your medical expenses and two-thirds of your lost income once your claim is approved. In order to file a claim, you don't have to prove your employer did anything wrong, and you cannot be fired for filing. Most South Carolina employers with four or more employees are required to carry workers' comp insurance.
The Benefits of Having a Nurse Case Manager
The job of an NCM assigned to you after a work-related injury or illness is to help you manage your medical care by:
- Getting approval from the insurance company for the cost of treatments and referrals
- Scheduling appointments with your primary physician and with any specialists or physical therapists to whom you're referred
- Making sure that you're able to get to all your appointments
- Seeing that you follow your doctor's advice and treatment guidelines
- Consulting with your doctors(s) about your diagnosis, prognosis, symptoms, medications, progress toward recovery, impairment or disability rating, and job restrictions
When you reach maximum medical improvement (MMI) and return to work or receive a disability rating, your NCM's job is finished.
The Potential Drawbacks of Having a Nurse Case Manager
While many NCMs are genuinely committed to helping their claimants recover fully, they do have a potential conflict of interest because they're hired and paid by the employer's insurance company, which likely wants to spend as little money as possible on medical bills and get the claimant back to work sooner rather than later.
What Is Considered Unacceptable NCM Behavior?
The insurer pays the NCM a salary. To justify that salary and keep the job, an NCM might not want your doctor to recommend expensive treatments or might encourage a return to work before you're really ready to resume your duties. In the worst scenarios, unacceptable NCM behavior might include:
- Disagreeing with your doctor's diagnosis or treatment plan
- Questioning the work restrictions you're given by your doctor
- Accusing you of exaggerating your symptoms or level of pain
- Inaccurately report the content of communications with your doctor
- Challenging your impairment rating
- Discouraging you from consulting an attorney about your case
This could be considered unethical behavior on the part of an NCM becuase it deprives you of your right to fair workers' comp benefits. In this case you're well justified in taking action to protect yourself.
Exercise Your Right to Protection
As a workers' comp claimant and a patient of your primary doctor, you have certain rights that you can exercise to protect yourself from any inappropriate behavior on the part of your NCM.
You Are Entitled to Private Medical Exams
Although your NCM is permitted to accompany you to your doctor's appointments, you have the right to be examined in private by your doctor. It's a good idea for you to exercise that right. When only you and your doctor are present, you can speak openly and honestly about your symptoms, pain, progress toward recovery, and anything else that the doctor needs to know. If you disagree with something the NCM has told you to do or not to do, discuss your options with your physician during your private exam.
You Have a Right to Full Disclosure of Doctor-NCM Meetings
Although the NCM has the right to consult with your doctor about your treatment and recovery, you have the right to be present during their meetings. You must also be given copies of any questions submitted to your doctor in advance, and your NCM's communications with your physician are not permitted to interfere with your treatment. If there is anything being discussed that you don't understand, ask questions. If you disagree with anything said or reported by either party, say so and demand clarification. If you can't get clear answers or you're still not satisfied with the role your NCM is playing in your recovery, contact a workers' comp attorney for a consultation on your case.
Have You Been Assigned a Nurse Care Manager After a Workers' Compensation Claim?
If you've been hurt at your job, you can speak with a workers' compensation lawyer. Please contact us online or call our Florence office directly at 843.488.7540 to schedule your consultation. We are also able to meet clients at our Conway, Florence, Myrtle Beach, Murrells Inlet, Mt. Pleasant, North Myrtle Beach, Charleston or North Charleston office locations.