Nurse or Medical Case Managers in Florida Workers' Comp Cases

While an adjuster in a case is just some voice on the other end of the phone to the injured worker, some insurance companies will hire nurse or medical case managers that are more physically present. These individuals are usually registered nurses or have some medical background and most often work for outside companies that contract with the insurance companies to help “manage” the medical part of a work comp case.

In some cases, nurse case managers are hired after an injury is first reported to develop a treatment plan intended for speedy recovery and return to work. At other times, they work in the field, going with the injured worker to doctor visits, making home visits to ensure injured workers are appropriately managing their care, or meeting with supervisors to arrange for modified duty or worksite modifications to enable the employee to return to work.

Although it is an added expense to a case (with fees ranging from $80 to $125 per hour), the purpose of having a nurse or medical case manager is to significantly reduce the duration and cost of workers’ compensation claim by guiding the injured employee’s medical treatment and return-to-work efforts. The idea is for the nurse case manager to help out in a work comp claim by advocating for the injured worker’s medical needs and ensuring a continuous flow of communication among providers, claims adjusters, the injured worker and the employer.

It all sounds great, doesn’t it? A win, win situation. The worker gets help with coordinating medical treatment and getting back to work, and the insurance company saves money by having a nurse monitor costs. And, the ideal situation described does happen from time to time. But, it often doesn’t end up so warm and fuzzy.

Florida law allows an insurance company to retain the services of the nurse case manager and allows the nurse case manager to talk to an injured worker’s authorized doctor without the worker being present. However, an injured worker has the right to insist on being able to go into his or her appointment with the doctor without the presence of the nurse case manager should this be desired.

Having a nurse case manager on a case may be a really good experience for the injured worker provided the health and well-being of the worker is the priority when measured against the monetary savings sought for the insurance company. While it’s certainly advisable for a nurse and doctor to discuss the most cost effective way to provide effective treatment, issues arise when the nurse becomes willing to put the injured worker’s medical recovery on the back burner in order to limit medical costs and rush the return to employment.

Our firm takes a rather cautionary approach to nurse case managers in work comp cases. Unless we have worked well with a particular nurse in the past, and have developed a certain level of trust, we send letters to the assigned nurse case manager and adjuster advising that all contact with the worker go through our office. Sometimes the coordination of medical appointments and transportation can run smoothly with the nurse case manager working directly with the injured worker, but even this administrative involvement has its problems if the nurse ends up being incompetent. Unfortunately, there is nothing we can do to limit the contact the nurse has with the authorized doctor(s).

Issues arise when the nurse case manager oversteps boundaries by pressuring the authorized doctor to pursue a less costly form of treatment/prescriptions (when this may not be the best for the worker) or place a worker at MMI and sign off on an earlier return to work release. The latter causes the worker to lose entitlement to additional disability benefits and puts them at risk for re-injury. Some nurse case managers even try to influence the doctor with insinuations the worker is exaggerating or overstating pain levels. Rather than facilitating the recovery of the injured worker, these nurse case managers are essentially the eyes and the ears of the adjuster, with the only real goal being that of minimizing cost to the insurance company without concern for the worker.

If you have a work comp case and a nurse case manager has been assigned, you may wish to consider speaking with an experienced attorney about your rights and options.
For a free consultation with one of our work comp attorneys, call (850) 795-4979.