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Case Management Scenario Questions

Posted

Specializes in Postpartum and Newborn. Has 1 years experience.

Hi all! I'm very interested in case management, and have been doing a lot of research into this specialty of nursing. I have been on a couple of interviews, and have been stumped by a couple of scenario questions... hoping someone could shed some light on appropriate answers to the following situations:

1) What do you do when a patient's injury is non-industrial in nature, but the patient does not have industrial coverage?

2) The injured worker has obtained legal representation, and requests for contact with him has been denied by the attorney. The worker has made several calls to you (the case manager) to request assistance with his claim. How do you handle this?

Thank you in advance for any insight you can share on these two scenarios!

SummerGarden, ADN, BSN, MSN, RN

Specializes in ED, ICU, MS/MT, PCU, CM, House Sup, Frontline mgr. Has 13 years experience.

Neither question makes any sense. Is it possible you have misworded them? Well, maybe number 1 makes some sense...??? Is it possible you were meaning to write that the patient has only industrial insurance? Or the patient was hurt industrially, but has no industrial insurance?

BTW, I doubt that if you did not or do not get case management jobs it will because you did not respond appropriately to CM questions. In general nurses new to case management require a lot of training. Maybe they want to make sure you are interested in this particular specialty? You will be surprised how many nurses enter this specialty without understanding case management and in some cases, mistakenly thinking that our jobs are easy. Thus, interviews are a great place for nurses to gain a better understanding of this specialty while employers are better able to sense if the nurse will be a good fit. Good luck.

I agree, need some clarification - your questions sound as if they are coming from the payer side - is your interview with an work comp insurance company?

If so, I worked WC/Ins many years ago, and the first things that popped into my head were these:

1) Refer the injured worker to their commercial coverage.

2) Refer the injured worker to the Claims Dept. Or, if it's a strict no-contact & you can't even tell him that, I'd call the atty's ofc and provide the appropriate Claims number for them or the IW to call directly (RN Case Managers have little/nothing to do with claims disputes).

Again, I'm winging it here because the scenario is a bit confusing to me, as well as what I would do may be severely outdated. I agree with PP, I doubt a company would nix you based on your responses to these questions, people new to CM would not necessarily know how to answer. Good luck to you!

Too late to edit my previous post, so I'll add here: (and this is still assuming the interviewing company is a WC insurer)

On second thought, #1) may be that they would want you to do an official denial as "other payer primary/responsible", or deny as ineligible as the injury is not work-related and the person doesn't have industrial coverage. Just in case a hospital or provider of some-sort tries to submit a claim at a later date there would be a denial on record so Claims doesn't accidentally pay. But, still not understanding why the company would even be involved if the person isn't insured by them, unless it's a company that has both commercial and WC policies.

Or, then again, they could both be trick questions and the real answer they want is "I'd look it up in the company's policy manual and see what the correct procedure is" LOL :grn:

Edited by freefalling

mclennan, BSN, RN

Specializes in CCM, PHN. Has 8 years experience.

As a longtime CM RN, I think Workers Comp CM is a different animal than other forms of CM.

And I agree, neither question made sense.

SPJJMommy

Specializes in Postpartum and Newborn. Has 1 years experience.

Thank you all for your input! Now I feel better about the fact that I didn't understand these questions... They don't make much sense to me either. I really do appreciate you guys taking a stab at it! I have an interview coming up, and the company sent these questions (and a bunch of other tough questions) for me to answer ahead of time. With no CM or Workers Comp experience, most of them were pretty tough for me to answer. I'll just do the best I can! Wish me luck! :)

1) What do you do when a patient's injury is non-industrial in nature, but the patient does not have industrial coverage?

2) The injured worker has obtained legal representation, and requests for contact with him has been denied by the attorney. The worker has made several calls to you (the case manager) to request assistance with his claim. How do you handle this?

1) You tell the adjuster that, because you have to. But depending on your relationship with the IW, you might recommend a provider that would be appropriate when you explain why you're not going to be working with him anymore. Of course, if the guy's a jerk and you have good reason to think he's been trying to scam you, you don't owe him nuthin', including the time of day.

2) "I'm sorry, but Attorney Smith says I can't talk to you. When he gives permission I would be happy to work with you. Please tell him you called me. Remember, he works for you, you don't work for him." Document these calls and report to adjuster, too.

Scenarios are a good way to understand the intricacies of case management. I would conclude that an interviewer who is asking you about this level of understanding of case management - is probably assuming you already have experience in case management. But - to address your questions:

In response to scenario 1: It is unclear how you received this case. Was it from an adjuster? If not then who? I am not clear about what led you to believe this was not a work related injury. Cases are not sent to a case manager in a work comp setting unless they have been reported by the employee to the employer and then the employer alerts their insurance carrier. This scenario is very lacking in enough detail to truly provide an informed answer. It is not up to the Case Manager to make a diagnosis or determine if an injury is work related.

In regards to Scenario 2: I generally agree with the answer submitted which refers to "Attorney Smith". I agree with the additional information for the claimant reminding him/her that the attorney works for the claimant - not the other way around. Generally speaking you can communicate with the claimant via mail (sent to the attorney) - just not in person or directly via telephone. Each state's workers comp laws are unique. It is important to understand your state's guidelines in this matter. Oftentimes, a claimant does not understand the role of the case manager. This information would be important to offer to the claimant in an acceptable format/venue/etc. so the claimant can make an informed decision. And lastly, it is always important to document, document, document.

2) "I'm sorry, but Attorney Smith says I can't talk to you. When he gives permission I would be happy to work with you. Please tell him you called me. Remember, he works for you, you don't work for him." Document these calls and report to adjuster, too.

I don't work in case management but I do have an interest and the questions do not make sense to me either. For the first question it's possible that, like in other interview situations, they just want to see how would you respond. Maybe they are looking for you to tell them that you don't have enough information to provide a proper answer. I'd also give them a couple of possible scenarios assuming some information that isn't actually given and maybe even include what someone else suggested and say that you would refer to the company's policy. For the second question, I agree with the others who say to refer him back to his attorney.