Worker's Comp Case Management - page 3

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   Louisiana RN
    Quote from lizz
    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.

    girl! you are full of questions! here goes .....not many go out on their own. most people must have the corporate framework because they need the benefits (insurance, paid time off) associated with the job, they do not want the risk of self employment, or they just don't have the confidence or discipline needed for self-employment. i am lucky because i don't need the benefits. my husband is also a nurse case manager with a national company and he is also retired military. therefore insurance is not an issue for us. we hope he can come on board with me in the future but he really likes what he is doing now and he is getting close to retirement time. i have never seen self employment as a risk because i have been a case manager for over 15 years and have a huge number of contacts in many states. i also know many plaintiff and defense attorneys who are referral sources to me. and face it, you should be able to tell that confidence is not a problem for me. i much prefer self employment because i get to set the rules, i have much more time off for more money in my pocket, and i don't have to play the corporate head games. i am not a political person and despise the headgames that are part of working for a large corporation. i am way too much of a rebel - makes me a good case manager and a poor corporate employee. the big companies are not hurting. in my state, maybe 1 in 15 case managers are independent. we only need about 15 cases to have a full case load and 7 cases, if worked properly, will net you as much pay as a full case load working for someone else will. many insurance companies in my state will not refer to a large company - they get better service for less cost with an independent. so, we don't take enough cases from the large companies to be a threat and fill a niche as well. i have a reputation as a trouble shooter and being very good with catastrophic cases. i also tend to get cases that have been open many years and have spun terribly out of control - therefore, my cases tend to be open 12-24 months. those kinds of cases are also very time intensive and usually have several physicians involved. that means i don't need a huge caseload to get the hours i want. the company i worked for was not pleased at losing me but i suspect they were also somewhat relieved - i was always the very squeaky wheel! i made them very much money but they had to put up with me in the process. the job is very complicated if done properly. one must know the laws of the state they are working in as each state has a different body of worker's comp law. i routinely work in 4 different states and have worked in 15 different states (from louisiana). you have to keep many parties, all with different issues, focused on the same goal. i explain myself as the hub of a many spoked wheel. i am the only one on my cases who knows every detail about my patients in all areas related to the job injury - medical, social, insurance, and legal. i keep all involved parties informed of what the other parties are doing and why. when there are 5-6 doctors involved as well, that can get pretty intense. patient/family teaching is another one of my soap boxes. how cases are worked is even another whole conversation (grin)! i worked for a company for three years before i went independent. during that time, i had 2 mentors who were phenomenal case managers. case managers now-a-days do not get the kind of training i got back then. the first week i came on board, i was handed a full copy of my state's statute, shown to a conference room, and told to read it from start to finish. three days later when i finished, i was told to read it again. i was then sent to a training school in another state for a week. when i returned, i then shadowed another case manager for 2 weeks before i was given my own cases. for the next 6 months, i had one of 2 supervisors on call at all times, day or night. in that first six months, i called them at least 10 times a day until i learned the ropes. every report was read and critiqued - i had to rewrite one 20 page report on a catastrophic patient 6 times because i was not maintaining neutrality and was showing too much bias. the problem i see nowadays is that many potentially good case managers do not get to realize their potential because they are not properly trained to begin with. for me, it is easy to balance patient care with cost issues. my job in worker's comp is to obtain the highest level of recovery possible in the most time and cost efficient manner so that patient can return to work. it is not my problem to cut the costs entirely, it is my job to control the costs as much as possible. the longer that patient is out, the longer the carrier is paying weekly benefits. however, i am a nurse first and i make no bones about that to any one. i make sure the carriers understand that if the most appropriate medical care is provided correctly the first time, then they save money by not having to pay for complications produced by shoddy medical care and the extended time it takes to recover from those complications. i advise them what is appropriate, what will produce benefit and what will not, why the patient is not recovering in appropriate time frames (legitimate or not), when paying for something extra will get them a faster more cost efficient recovery etc. the time (thus the cost) it takes to deliver patient teaching is offset by the increased level of participation and cooperation from the patient which also shortens recovery time. then, if there is not proper compliance and participation, the carrier has the documentation they need for noncompliance and can stop the benefits. stopping those weekly benefits usually gets instant cooperation from the patient! my patients are usually minimally educated rural working guys who are in no way equipped to talk to a physician well. i make sure all physicians know exactly what is going on with their patient in all aspects of their life and what the other treating physicians are doing and why. i am really a medical interpreter. when physicians talk doctor talk to the patient, i then make sure the patient fully understands what that doctor told them. you would be amazed at how little a patient hears of what a doctor actually tells them. in short, if i treat & manage my patients as a nurse should be treating them, all the things the patient, the doctor, and the carrier want to see will follow. next question?
  2. by   marya
    Quote from DallasRN
    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 claims and claimants from a variety of states and would be interested in developing a network of other CM's to answer occasional questions regarding specific state laws/rules, doctors, etc. For example, I have now learned (the hard way) that if a claimant in Georgia refuses CM services, a CM cannot be involved in any aspect of the claim, and in TN, CM is mandated by law when claims costs reach $2500.
    Anyone else interested in communicating and developing a network within this network? And certainly, I would always be more than happy to share info regarding Texas!
    Thanks and hope to hear from you.
    Susan
    I have 15 plus years work comp case management with Iowa, Ill and Wis.
    I am interested in telephonic work comp case management.
    Do you have need?----Or are you aware of companies who use telephonic RN work comp case manageres?
  3. by   alintanurse
    Quote from DallasRN
    Hello to all CM's. I just joined this site because I am comp case management. I am an independent; however, I work with claims and claimants from a variety of states and would be interested in developing a network of other CM's to answer occasional questions regarding specific state laws/rules, doctors, etc. For example, I have now learned (the hard way) that if a claimant in Georgia refuses CM services, a CM cannot be involved in any aspect of the claim, and in TN, CM is mandated by law when claims costs reach $2500.
    Anyone else interested in communicating and developing a network within this network? And certainly, I would always be more than happy to share info regarding Texas!
    Thanks and hope to hear from you.
    Susan
    Susan, I am new to worker's comp case management,what do you mean "you learned the hard way" re:when a worker refuses case manangement services. Could you elaborate on this?Thankyou
  4. by   DallasRN
    Quote from alintanurse
    Susan, I am new to worker's comp case management,what do you mean "you learned the hard way" re:when a worker refuses case manangement services. Could you elaborate on this?Thankyou
    Hi there, alintanurse. Gosh, that was posted so long ago...what was going on then? I was working for a carrier at the time that assigned me a claim to handle telephonically in Georgia (from Texas). She also wanted field CM assigned. I contacted the claimant, talked to him for a while, then contacted a CM company in GA to assign a nurse. Later, I got a call from the claimant's attorney...he had previously refused CM and by Georgia law, CM's were not allowed to contact him. That's the best I recall. Anyway, the attorney was quite nice and pleasant - not a problem, but I felt like a real goofus.

    Another poster made some excellent comments regarding knowing the laws of the states you are handling cases in. The actual nursing aspects of CM are the same, but when dealing with comp, the laws are so varied from state to state that it is difficult when you are handling multi-jurisdictional cases. Additionally, you are walking a fine line between being a patient advocate and being an advocate for the insurance carrier. After all, they are your payor source and I've found many adjusters to be less than...shall we say "ethical" when it comes to handling their claims. That can have a significant impact on the way the CM handles the claim.

    Louisiana RN noted "For me, it is easy to balance patient care with cost issues. My job in worker's comp is to obtain the highest level of recovery possible in the most time and cost efficient manner so that patient can return to work. It is not my problem to cut the costs entirely, it is my job to control the costs as much as possible."

    A true statement when it can be affected. However, your "job" as a CM is frequently made more difficult by carrier denials of treatment, etc. By that, I mean...if you have a patient that is going to benefit from surgery, additional surgery, additional time off, different treatment, a change of physician or a multitude of other issues, and the carrier rep is resistant, you are not going to be as successful as Louisiana RN reports. What do you do when you have a patient with chronic pain, pain program has been recommended, carrier refuses, shoots off a RME request, and patient is sent back to work too early. Then, days or weeks later, additional injury, back on the comp roles. Were you effective? Yes and no. As effective as you could be, but ineffective in that you did not get the necessary treatment for the patient.

    Comp is a can of worms. I recently stopped doing all comp and got involved in home health. Love it, hate the pay! Loved the pay of comp, hated the work in the end. There needs to be a happy medium somewhere. I'm looking.
  5. by   alintanurse
    Quote from DallasRN
    Hi there, alintanurse. Gosh, that was posted so long ago...what was going on then? I was working for a carrier at the time that assigned me a claim to handle telephonically in Georgia (from Texas). She also wanted field CM assigned. I contacted the claimant, talked to him for a while, then contacted a CM company in GA to assign a nurse. Later, I got a call from the claimant's attorney...he had previously refused CM and by Georgia law, CM's were not allowed to contact him. That's the best I recall. Anyway, the attorney was quite nice and pleasant - not a problem, but I felt like a real goofus.

    Another poster made some excellent comments regarding knowing the laws of the states you are handling cases in. The actual nursing aspects of CM are the same, but when dealing with comp, the laws are so varied from state to state that it is difficult when you are handling multi-jurisdictional cases. Additionally, you are walking a fine line between being a patient advocate and being an advocate for the insurance carrier. After all, they are your payor source and I've found many adjusters to be less than...shall we say "ethical" when it comes to handling their claims. That can have a significant impact on the way the CM handles the claim.

    Louisiana RN noted "For me, it is easy to balance patient care with cost issues. My job in worker's comp is to obtain the highest level of recovery possible in the most time and cost efficient manner so that patient can return to work. It is not my problem to cut the costs entirely, it is my job to control the costs as much as possible."

    A true statement when it can be affected. However, your "job" as a CM is frequently made more difficult by carrier denials of treatment, etc. By that, I mean...if you have a patient that is going to benefit from surgery, additional surgery, additional time off, different treatment, a change of physician or a multitude of other issues, and the carrier rep is resistant, you are not going to be as successful as Louisiana RN reports. What do you do when you have a patient with chronic pain, pain program has been recommended, carrier refuses, shoots off a RME request, and patient is sent back to work too early. Then, days or weeks later, additional injury, back on the comp roles. Were you effective? Yes and no. As effective as you could be, but ineffective in that you did not get the necessary treatment for the patient.

    Comp is a can of worms. I recently stopped doing all comp and got involved in home health. Love it, hate the pay! Loved the pay of comp, hated the work in the end. There needs to be a happy medium somewhere. I'm looking.
    Thankyou for your quick reply Dallas RN, I find it interesting that you are now doing Home Health as I am currently working for a Home Health agency also. The pay here is very good but I had been doing Home health for many years previously. I like the combination of the two,I'm able to maintain my nursing skills while learning my new position. Anyway-Have a Happy New Year! :hatparty:
  6. by   sflohaug
    Hi,
    I am new to this thread. I have experience as a telephone triage/advice nurse and recently worked in WC as an independent contractor.
    Do you know of any companies based in California or elsewhere that are hiring CM nurses that can be home-based??
    Thanks for your time and help!

    Sharon in CA
  7. by   EGPRN
    Quote from alintanurse
    Susan, I am new to worker's comp case management,what do you mean "you learned the hard way" re:when a worker refuses case manangement services. Could you elaborate on this?Thankyou

    Susan
    I just joined this site and hope I am replying correctly:-)
    I have just gone off on my own and and independ. contracto/ Case Manager for W/comp and disability claims. I have search high and low for samples of client contracts. I need to get my contracts together to approach the insurance industry and I cannot seem to access a resourse for sample contracts, fee schedules ect. Any ideas...anyone??
    Eleni
  8. by   rntx
    Does anyone have any opinions about working for Excel Managed Care???
  9. by   LNZMLY
    I need help. I am to be doing telephonic case mgt in ky, sc and va. I am not licensed in those states. Am I going to need a license in every state I am assigned. How does this work?
  10. by   Louisiana RN
    i got your message on the same day i got the newsletter from the case management society of america. below is part of that newsletter that should answer your question. in short, yes you have to be licensed in each state that you have a patient residing in.
    nurse licensure is regulated on a state-by-state basis with state boards of nursing requiring nurse case managers to be licensed within the states where patients reside whenever telephonic or on-site interactions occur with patients. when nurses provide case management services telephonically or onsite without a license to practice in the state of the patient's residence, he/she is violating the law. the violation is punishable with penalties of up to $1000, permanent loss of licensure, and up to one year in jail.

    of additional concern to nurse case managers is the fact that no professional liability insurance carrier will cover an improperly licensed or non-licensed nurse in the event of actions which are deemed damaging to the patient. therefore, case managers would be personally responsible for payment of damages if they are assessed.

    through the national council of state boards of nursing (ncsbn), 20 states have entered into a compact to recognize other states' licensing of nurses. a listing as of august 2005 is included below. the compact is tied to the state of the nurse's residence, not the state of practice or the patient's location. therefore, if a nurse resides in and is licensed by a state that participates in the nurse licensure compact, the nurse's licensure will be recognized by other states participating in the compact.

    jeanne boling, msn, crrn, cdms, ccm, cmsa executive director explained, "the purpose of the cmsa position statement is to alert and to persuade individuals and organizations to aggressively encourage non-compact state boards of nursing to join the compact and to encourage federal legislation mandating recognition of nurse licensure across state lines in the same manner as drivers licenses are recognized."

    according to rogers, "in response to this issue, cmsa is encouraging case managers and case manager employers to work aggressively with the state boards of nursing to encourage compliance and entry into the ncsbn as compact states so that appropriate multi-state nursing licensure might continue appropriately and cost effectively. in addition, or as an alternate step, cmsa is encouraging the enactment of federal legislation mandating the recognition of nurse licensure in all states. finally, cmsa has added its name to the growing list of those organizations supporting and endorsing the nurse compact."

    hope this helps!:santa3:

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