Worker's Comp Case Management

Louisiana RN · Aug 29, 2004

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. :rolleyes:

Sheri257 · Aug 29, 2004

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.

:clown:

Louisiana RN · Aug 30, 2004

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?

marya · Nov 28, 2004

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?

alintanurse · Jan 1, 2005

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

DallasRN · Jan 2, 2005

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.

alintanurse · Jan 2, 2005

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!

sflohaug · Jan 25, 2005

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

sflohaug · Jan 25, 2005

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

EGPRN · Sep 19, 2005

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

rntx · Sep 26, 2005

Does anyone have any opinions about working for Excel Managed Care???

LNZMLY · Dec 23, 2005

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?