Worker's Comp Case Management - page 2

Hello to all CM's. I just joined this site because I am particularly interested in communicating with other CM's involved in worker's comp case management. I am an independent; however, I work with... Read More

  1. by   DallasRN
    Your volunteer job sounds interesting to say the least. I would imagine it could conceivably end up requiring a great deal of time and thought. I bet you've learned tons of things!

    Thanks for the ideas about getting the IME doc to clarify things. In the past I have frequently tried to use the leaders of various professional groups for peers, etc., and on occasion, have requested a peer review of sorts in which the peer physician would make direct physician-to-physician contact to discuss treatment plans, surgeries, etc. I have found that some physician's that refuse to meet with and/or respond to CM's will readily do so with another MD. (And I really can't blame them - I get a tad irritated when I contact a physician's office to discuss something with the physician or nurse and end up talking with a medical assistant).
    I'll look into your idea. And as for Las Vegas RN - I am STILL laughing about that!! - Susan
  2. by   LasVegasRN
    I've used Sharon's idea also, but in the state I was working, it was not admissable as evidence. The trick we had to use was to get the original physician who reviewed the case to comment on the consulting physician report in their new report. THEN it was admissable. Lot's of silly legal maneuvering but it worked in case's like yours, for that particular state.

    I would try petitioning the state. If you can present strong evidence that the report was insufficient you may prevail. You really have to see how much leg you have to stand on - if it is worth the fight. Even if you get a rock solid report from a well-respected peer than can refute the items of question in the report, it will still be difficult to convince the reviewing body that it is more valid than the physician's who actually "examined" the patient.

    Good luck!
  3. by   Sharon
    Just to clarify - I don't use the peer in this situation for another report. I use them to pressure or shame the IME physician to addendum their original report. I agree it rarely is cost efficient to have a third round of reports
  4. by   ryaninmtv
    OMG Vegas!!! FOFLMAO!!!

    Can I copy your post and put it in my letters database at work? That is just what we need.

    One thing we have done is instead of have the WC adjuster write the letter to examining physician, I have one of my nurses do it. This avoids most of the cookbook BS I see in adjuster manuals and allows us to write a medically based letter to the physician. Of course, what I mean by medically based is that we try to word the questions so that the doc has no choice to lead us down the primrose path. Also, in a state as incestuous as Ohio, we pretty much know which docs are conservative and which are liberal. In my group, which handles self-insured employers, we literally have docs knocking down the door to do IMEs for us. This is because we are not constrained by the BWC fee schedule for IMEs and a doc can make serious coin if he has a good reputation among the self-insured employers.

    As far as what to do in your particular case, I would ask the physician for an "addendum" to clarify his remarks (read:rewrite your report so I'm not screwed).

    Good Luck!!
  5. by   Louisiana RN
    Hi Guys!
    I am new to this so be patient. I do not use chat room, instant messaging etc. as a rule so I am totally unsure of what I am doing. However, the messages I read here sounded really interesting to me. I have been a nurse x 30 years and a case manager in worker's comp in Louisiana x 15 years. Talk about complicated set of law! Have worked cases based on many other state's body of law over the years including Texas. Looks like there has been no one at home here in a while but that could be because I don't know what I am looking at. So, anybody at home??
  6. by   denicke
    Hi, Louisiana RN, another LA RN here as well. I've been a nurse for over 25 years and I'm interested in the area of WC case management. How did you get into it, what classes should I/could I take to prepare, how difficult a field is it to break into and learn?
  7. by   lifeisbeautiful
    I am in the middle of a nasty Workman's Comp claim now. I have been out of work since Feb. They are "delaying" my claim and it has been over 90 days! I have been dx with Latex induced Anaphylaxis (Type 1 LA). I have been denied clearance to work by the hospital MD, my Allergist, and the Workman's Comp. MD. I was so sick at work, they finally did a blood test that confirmed my dx. My RAST was >2000...normal levels are <70. I can't even find a good lawyer to help me
  8. by   Louisiana RN
    Hi denicke! I stumbled into it years ago when I was recruited for the job and just found my niche. There are no real classes you can take and it is mostly OJT; There is a certification (Certified Case Manager) that is pretty much required now but you have to have worked as a case manager under supervision of a CCM for 1-2 years before your an sit for the exam. Normally to break into it, one has to land a job with one of the national companies until you get dry behind the ears - Intracorp, Concentra, Gen-Ex, Jennifer Palmer etc. It is not real hard to get into because the big companies have a really hard time keeping good case managers for any extended time period (that's a whole nother discussion).You just have to keep trying and bide your time. WC case management is very different from in-house case management and a nurse in one type will not necessarily be able to do the other type. I've done both and really dislike in-house case mgmt.
  9. by   Louisiana RN
    Where are you from? Each state of the union has a different set of comp law which means they can and cannot do different things. Who is your WC insurance company? Most people fail to understand that in the world of worker's comp things rarely proceed anywhere near as fast as it does in private health care - tends to be a real rude awakening. They may not be delaying so much as they do not have the information needed to proceed. Additionally, many of the adjusters are so overloaded that only the squeaky wheel gets any grease. I will admit there are nasty adjusters out there but often it is a matter of very poor, inadequate, or inaccurate communication on all sides. On the face of it, A latex allergy would appear to be a pretty cut and dried issue but I do not know enough details to help you. You really need to try to resolve this yourself before getting a lawyer because I can assure you the minute a lawyer gets involved, it is likely to get nastier than it may already be.
  10. by   denicke
    Thanks for the info! I'll keep my ears open.
  11. by   Sheri257
    Quote from Louisiana RN
    It is not real hard to get into because the big companies have a really hard time keeping good case managers for any extended time period (that's a whole nother discussion).
    Could you elaborate? I'm really curious about your thoughts on this, and why they have trouble keeping case managers.

  12. by   Louisiana RN
    Quote from lizz
    could you elaborate? i'm really curious about your thoughts on this, and why they have trouble keeping case managers.

    case mgmt is predicated on nursing ethics. the prime issue is to recommend what is most medically appropriate for the patient while controlling costs and time as much as possible. that is not the goal of the corporate case mgmt company (despite their pr) or, to a large extent, many insurance companies. consequently, there is a constant battle to keep your job with a corporation interested solely in the profit margin and keeping your nursing license without violating nursing ethics. the large worker's comp case mgt companies are running a national corporation and they have corporate rules, requirements, etc. that are geared for running a business for the maximum profit over an entire nation. they cannot gear their policies for what is workable in a particular area and therefore they do not provide a great set-up (customer or employee) in any one region - just mediocre at best. they provide minimum training (costs too much) and do not set themselves up to keep the type of people who are the natural talent for this job. their sales reps often make contracts with insurance companies containing unrealistic billing guidelines and expect the field people to meet those guidelines. if the guidelines are not met, they expect the case manager to eat the difference (ie not paid for). examples include maximum travel time limits that will not permit the task to be completed, not enough report time permitted to properly document activities. the companies get many people who start the job and find their personality is not suited to it, get too overwhelmed with the complexities of worker's comp with no in depth training to back them up, find they do not like the isolated work environment, or dislike the frequently long or erratic hours involved. therefore, they start the job and quit 2-6 months later. the large companies expect case managers to put far more of their private resources into the job than most people will accept - case mgr must purchase their own fax, copier, etc. but the company's customer contract does not permit billing for fax/copying costs. guess who the company expects to eat that cost unless the case mgr gets creative in her billing? successful field case mgmt requires a diplomatically aggressive, assertive, flexible person with a talent for watching costs, managing details, and creative problem solving coupled with a huge sense of time efficiency. these are not people who are going to tolerate the corporate world's penchant for passing costs to the field staff, demanding unpaid worktime, & incessant inane paperwork that accomplishes nothing but corporate justifications. therefore, the talented case managers stay on long enough to learn the job, gain their certifications, and gain the needed contacts. then they go into business for themselves (like me) making a large amount of money for very little business overhead and provide a better quality of service for less cost to the carrier in the process. the constant turnover of either unsuitable employees or talented people too smart to stay long means the large companies are always looking for people. they may not need anyone for 6-12 months and then suddenly, they have 3 people walk out. wait long enough and put your resume out and it is not hard to get into case mgmt. it is hard to stay in case mgmt with a large company because they want far too much sugar for their dime. sorry this is so long, but you asked. believe me, i could talk your ear off on this subject.
  13. by   Sheri257
    Quote from louisiana rn
    therefore, the talented case managers stay on long enough to learn the job, gain their certifications, and gain the needed contacts. then they go into business for themselves (like me) making a large amount of money for very little business overhead and provide a better quality of service for less cost to the carrier in the process.
    well, your post wasn't too long at all. i find this fascinating. how many people would you estimate do what you did ... going out on their own, that is? are the big companies hurting as a result? this sounds like a very complicated job. how long did you work in the field before you went out on your own? and how do you balance the ethics of patient care versus cost issues?

    thanks so much for this information.


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