Worker's Comp Case Management

Sharon · Oct 23, 2002

DallasRN

For the law enforcement and non profits that I volunteer my services, I do case management, performance issues and compliance with federal and state employment regulations and laws. This way I get more of my esoteric and humorous experiences.

Las VegasRN did a great job with the letter. Another method I use is I call the back to school method. I contact a specialists whose written format has been useful in the past ideally a Professor of Medicine (if possible one of the current Board of Governor members of the creditaling body) and hire him to contact the IME/RME physician to clarify the questions. Then of course I do not use them again.

By the way, I have found using a Professor of Medicine is more likely to document a need for additional testing including psychological. As a group they are more expensive so I reserve them for my cases that cause me constipation or diarrhea.

DallasRN · Oct 23, 2002

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

LasVegasRN · Oct 23, 2002

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!

Sharon · Oct 23, 2002

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

ryaninmtv, ADN, ASN, BSN, MSN, LPN, RN · Oct 23, 2002

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!!

Louisiana RN · May 25, 2004

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??

denicke · Jun 16, 2004

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?

lifeisbeautiful · Jun 17, 2004

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

Louisiana RN · Jun 17, 2004

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.:)

Louisiana RN · Jun 17, 2004

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. :)

denicke · Jun 24, 2004

Thanks for the info! I'll keep my ears open.

Sheri257 · Aug 29, 2004

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.

:confused: