Nurse Case Managers: What To Know When One Has Been Assigned To Your Workers' Comp Claim

Posted on: 2 December 2015

What's a Nurse Case Manager (NCM) and why has one suddenly been assigned to your workers' compensation claim? What can you do to limit one from needlessly interfering in your medical care?

Nurse Case Managers Are Assigned To High-Risk Claims

The presence of the NCM on your claim indicates that the insurance company paying your workers' comp claim considers you to be a "high-risk" claim. What that means in plain english is that they're worried about how much money your care is costing. NCMs are typically assigned to cases when you've been out of work for a while, have had surgery but have been slow to heal, or when you have another medical condition that is affecting your ability to heal, like diabetes. 

Why are they a problem for workers' comp claimants? There are several reasons:

  • Their interests directly compete with yours. Their goal is to drive down medical costs for the insurer. They get evaluated by the value they provide the insurance company, not you.
  • Their job is to get between you and your doctor. This is supposed to help you communicate better with your doctor, which means that they presume that you aren't able to speak for yourself.
  • Doctors are already required to submit reports to the insurance company in order to get paid. The only reason for the NCM to speak to your doctor in person is to try to talk the doctor into changing your care, reducing your limitations, or returning you to work.
  • They will try to steer you away from "inappropriate" medical providers. That means that they will try to steer you toward doctors that are more compliant with the insurance company's demands.

You Can Limit The Nurse Case Manager's Role

The best way to limit the impact of the NCM on your case is to put limits on the NCM's access to your doctor. Depending on the laws in your state, you have several options:

  • Your attorney may be able to fire the NCM from your case. Since the NCM's function is, superficially, to represent you in front of the doctor and the insurance company, that's a redundant measure if you already have an attorney. That's why your attorney can fire the NCM in states like Illinois.
  • If your attorney can't fire the NCM in your state, he or she can limit how much you have to deal with the problem. Your attorney can oblige the NCM to talk to him or her, not you.
  • In some states, you can deny permission for the NCM to speak with your doctor.
  • If your state requires you to allow the NCM to go to appointments with you, you still don't have to let him or her into the exam room with you. Give the NCM written notice that you don't want him or her in the exam room.
  • If you can't stop the NCM from speaking with your doctor about your recovery, you can tell the doctor that you want to be present for any conversation about you and your care. That way you can make sure that the doctor is telling the NCM the same things that you're being told about your recovery, your limitations, and your ability to return to work.

The presence of the NCM is a sure sign that the insurance company is trying to minimize their expenses with you, which may mean trying to prematurely close out your case. If you don't have an attorney, get one. That way you can minimize the ability of the NCM to interfere with your care. Click her for more info on how an attorney can help you.