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Helllloooo Nurse (Case Manager)!

A nurse case manager assists applicants in administering their benefits, particularly medical benefits.  This service involves scheduling appointments, coordinating transportation, and speaking with treating physicians about the nature and extent of care, often informing the party stuck with the bill, the self-insured employer or insurance company, of what’s going on.

This service is paid for by the party liable for the future medical treatment, and is one of the recognized forms of “treatment” under Labor Code § 4600, if it is “reasonably required to cure or relieve the injured worker from the effects of his or her injury.”

Bear in mind, unlike a typical nurse, a Nurse Case Manager does not provide actual treatment.  This job generally entails providing some sort of realistic anchor in speaking with the treating physicians and keeping the insurer/employer appraised of the situation.  This way, doctors are not swayed into recommending elbow surgery under a lower extremity medical award.

But who gets to choose the Nurse Case Manager, if one is to be provided?  California Workers’ Compensation law provides that an employee may choose his or her own treating physician.  (Labor Code § 4601).  Even with the Medical Provider Network limitations of Labor Code § 4616, the employee still has his or her choice of physician within the network.

As for the Qualified Medical Evaluator, the panel process outlined in Labor Code § 4062.2 controls that choice, with each party striking one of three panel physicians until there is only one left standing.  Yet the law is relatively silent as to who gets to choose the Nurse Case Manager.

Whoever controls the Nurse Case Manager controls the flow of information to the insurer and the treating physician (some of it at least).  Understandably, there is something at stake here.

In the case of Lamin v. City of Los Angeles (2004), the Workers’ Compensation Appeals Board addressed this issue, and, having procured a magician’s hat and wand, mystically waved the latter and pulled the following “preferred” process from the former:

1)      The defendant is to appoint a nurse case manager;

2)      If the applicant objects, the parties are to try to reach an agreement and appoint an “Agreed Nurse Case Manager”; and

3)      If no agreement can be reached, the Workers’ Compensation Judge is to appoint a Nurse Case Manager, considering each candidate’s (a) training, experience, qualifications, skills, and effectiveness; (b) potential conflict of interest; and (c) the recommendations of the treating physician.

It’s hard not to be cynical as a workers’ compensation defense attorney, and I’m trying my best, but the defendant is to have no control at all over this treatment?  A nurse case manager is supposed to be a professional and impartial observer, making sure the treating physicians get the actual facts and the insurer doesn’t get robbed.

Next, the applicant will demand to choose his own transportation company, his own adjusters, and (eventually) his own defense attorneys to deal with (exaggeration, I know).

The waters have been fairly calm on this issue of late, but sooner or later this issue will come forward again and hopefully we’ll get a different decision on appeal.   Have you ever had an applicant demand his or her choice in Nurse Case Manager?  Let me know:  gregory.grinberg@htklaw.com

Categories: Nurse Case Manager
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