Main Takeaways:

  • A nurse case manager monitors your care and reports back to the insurance adjuster.
  • There are several ways to deal with your nurse case manager so you can have the best outcome including: insisting on a private examination by your doctor, not letting the nurse case manager switch your treating physician without your consent, and keeping your lawyer informed.

What Does the Nurse Case Manager Do?

A nurse case manager may be assigned to your case. The role of the nurse case manager is to monitor your care and report back to the insurance adjuster. Many times, there may be underlying pressure on the doctor to force an injured worker back to work too quickly or to suggest cheaper medical treatment as opposed to what a physician may truly want to do.

Never forget who is paying the nurse case manager and that they have an agenda to save the insurance company money. Many times, a nurse case manager can convince a doctor to release an injured worker back to work even if the doctor had not originally intended to do so. Other times, they may recommend to the insurance company to deny the recommended treatment because, in their opinion, they don’t feel that it’s necessary. Although there are some good nurse case managers out there with a genuine desire to help, many times it appears they are more interested in helping the carrier and employer.

Here is a case in point that has happened to more than one of my clients:

They leave an appointment with the nurse case manager still there with the doctor, and get a call the next day from their employer saying they are fired because they didn’t show up for work and that the doctor had released them to full duty. The nurse case manager got the doctor to “adjust” the work restrictions, gave it to the employer, and “forgot” to inform the injured worker. Don’t forget, the nurse case manager is working for the insurance company.

How to Deal with Your Nurse Case Manager

Always insist upon a private examination by your doctor outside the presence of the nurse case manager.

You have the right to a private examination with your physician. This will give you an opportunity to discuss your medical issues privately with your doctor. If the nurse case manager walks into the room, you simply ask the doctor if there could be some privacy during your meeting with him and, hopefully, that will do the trick and he will ask the nurse case manager to leave and come back at the end of the appointment.

A second part of this is to try to avoid having the nurse case manager talking privately with your physician by staying present until the end of the appointment. If the nurse case manager asks to speak to the doctor privately, you ask to join in that conversation.

Never let the nurse case manager switch your treating physician without your consent

Put briefly, this comes close to violating the worker comp rules. Sometimes, a nurse case manager will try to switch your physician when the physician’s medical opinion of your condition is inconvenient for the insurance adjuster, particularly in questions of work restrictions and your capacity to work.

This “doctor shopping” is an outright abuse of the system.

In some cases, the nurse case manager may tell you that the doctor you’ve selected isn’t available for the next month, but you could see another doctor this week. My suggestion is to set the appointment for next month and tell the receptionist to call you if there are any cancellations so you could come in immediately.

Insurance companies have sent injured workers to one of a few doctors who regularly give second opinions that clear the worker for returning to work with minimal or no restrictions. These unscrupulous physicians are paid handsomely for their compliance with the insurance companies, which will go to extreme lengths to get injured workers into the offices of these paid-off doctors. This practice is not only unfortunate, but is also outright wrong – sadly, however, many injured workers are taken advantage of because they don’t know what their rights are, or they don’t know how to protect those rights.

Keep your lawyer informed.

You need to keep your lawyer informed of any significant discussions that you may have with your nurse case manager. It is essential for you to keep your lawyer informed if you feel that your nurse case manager is taking a position contrary to your interests or is working against you in obvious ways. Any concerns that you have with your nurse case manager should be discussed with your attorney.

Difference Between Good and Bad Nurse Case Managers

A bad nurse case manager can be seen pressuring your doctor to force injured workers to return to work too soon. They also may try to convince your doctor to suggest treatment that’s much cheaper than the treatment other qualified physicians would order.

Since your nurse case manager is working for the insurance company, he or she most likely will have the intentions of trying to lower your disability rating.

Worker’s compensation is supposed to be in your favor when you suffer legitimate workplace injuries. However, a nurse case manager who isn’t looking out for your best interests may tell the insurer to deny treatment that they don’t think is necessary.

A good Virginia Workers’ Compensation nurse case manager, on the other hand, may work hard to get your doctor-recommended procedures approved quickly and help coordinate your care if you require multiple specialists.