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A series of articles emphasizing practical
knowledge you can't find in practice guides
and interviews with experts who share
their techniques for effective and efficient
case management
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Articles emphasizing practical knowledge you can't find in practice guides
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Profiles of people who changed workers’ compensation law.
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• Warren Schneider
• Marjory Harris
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HARRIS: As an applicant's attorney, I have found
sometimes that a Nurse Case Manager (NCM)
may play a valuable role, coordinating care,
making sure the treating physicians follow the
standard of care, and the like. I believe the primary
goal of the NCM should be to ensure quality
medical care. Yet like many applicants’ attorneys,
I have had negative experiences with NCMs and
in general perceive them as the enemy, snooping
for the insurance company and curtailing
necessary treatment. How do you deal with this
negative attitude?
BOWERS: Unfortunately, the
negative attitude which
you refer to, is perceived today among many
applicant attorneys. Permission of a nurse case
manager is often denied because of a past negative
experience or misperception of the nurse’s role.
There are many good nurses who have been viewed
as the enemy by many applicant attorneys, as you
have shared. In my practice, I have approached this
negativity, one attorney at a time. Changing the view
that the nurse is the “enemy and snooping for the
insurance company” is part of my professional
challenge to change the perception of the role of a
nurse case manager. The nurse’s role is not to
interfere with the client or treatment. The role should
include doing the right thing in a collaborative effort–
for all parties. Should it not be our common goal to
restore the injured individual to a prior level of health,
function, and return to prior quality of life?
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HARRIS: What is the role
of the nurse case
manager in a workers' compensation case?
BOWERS: The nurse case manager’s role is to be
an advocate of the process. The nurse is to be a
facilitator of information regarding medical care,
facilitator of authorizations and communications,
coordinator of care, collaborator between all parties,
and facilitator of information to keep all parties
updated in status and changes to the case.
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The NCM’s role is to be a facilitator and coordinator
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HARRIS: What kinds of
services do you generally
provide?
BOWERS: As a nurse case manager, nurses will
attend office visits with the injured worker and the
physician, coordinate medical treatment, requests
for diagnostic testing, treatment, arrange for home
health care, durable medical equipment,
transportation, translation, discharge coordination
from hospitals to home or skilled nursing
environments, provide up-to-date communications
to all parties so that current and timely information
and communication is provided. The nurse acts
as the “hub” of information and facilitator in
coordinating the physician’s requested treatment.
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HARRIS: Do you think a NCM
should advise all
concerned of appropriate treatments, going
beyond the purview of the individual Primary
Treating Physician?
BOWERS: The nurse case manager should keep all
parties advised of current treatment, treatment
requests, progress, lack of progress or improvement,
and any changes in function or status of the injured
worker (both positive and negative changes).
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HARRIS: I have wished for
some time that NCMs
did not just tell the adjuster how to cut costs but
could help both sides assess the cost of future
medical treatment, so that the adjuster could
increase reserves if necessary and the
applicant's attorney could make an accurate
demand for settlement of future medical costs.
Do you provide estimates of future medical care
if requested by the applicant's attorney?
BOWERS: In my practice as an NCM, cutting costs
is not something I practice - being cost effective is.
Oftentimes, carriers have their own networks in
place and the nurse is directed to utilize the
services of those contracted providers. Cost-cutting
has already been put in place before a nurse is
ever assigned to a case. Being aware and being
financially prudent as a case manager, is both cost
and treatment effective for the injured worker.
Nurses are often instrumental in assisting the
carriers in projecting needs for future medical care
to set reserves. Nurses are able to assist attorneys
in obtaining cost estimates in the event of future
medical care if requested.
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HARRIS: The 24-session
limit on physical and
occupational therapy for injuries on or after
January 1, 2004 can have a severe impact on an
injured worker's ability to return to work or avoid
being permanently crippled. How do you deal with
this issue?
BOWERS: There are often many situations in which
the nurse may find that the 24 cap on a particular
diagnosis will not be sufficient to restore the injured
worker to health or function. As the case manager,
the nurse should be pro-actively involved with the
injured worker and physician evaluating progress.
The nurse is instrumental in preparing the carrier for
any potential additional recommendations that may
be requested to restore health to the injured worker.
Oftentimes, the nurse is able to negotiate
authorization beyond the 24.
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HARRIS: How do you
maintain your independence
as a healthcare professional when your business
depends on corporate contracts?
BOWERS: Many nurse case managers have earned
the respect of the medical, legal, and carrier
communities. The nurse must remain objective
and do the right thing for all involved parties. This
allows independence as a healthcare professional
without the need for corporate contracts.
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The nurse must remain objective and do the right thing for all involved
parties.
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HARRIS: What do you think
of the way utilization
review is handled in the workers’ compensation
system, as compared to private medical
insurance? Do you have any suggestions for
change?
BOWERS: Utilization Review has definitely had a
significant impact in Workers’ Compensation.
Currently, there are no standards of practice among
the carriers with regard to the handling of Utilization
Review. Each carrier has adopted individual
guidelines and interpretations of the reform which
can make this difficult for the nurse case manager.
In Workers’ Compensation, the guidelines provide
a timeline for approval or denial of treatment. Group
health or private medical insurance requests often
are “stuck” in the myriad of paperwork with no time
parameters for decisions to be made. Group health
would benefit by nurse case managers who facilitate
and coordinate care in this venue. Delays in
treatment requests would be greatly reduced.
Timely follow up and treatment would be greatly
improved.
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HARRIS: If you could
change the current landscape
of workers’ compensation medical treatment and
create the ideal treatment environment, what would
it look like?
BOWERS: If I personally could change the current
landscape and create the ideal treatment
environment, it would be all parties (nurse,
physician, carrier, injured worker, and the attorney)
all working together to obtain the quickest, most
effective and appropriate medical treatment to
restore the individual back to the prior quality of life.
This would be ideally done within the first several
days, or weeks, of an injury (Early Intervention).
Literature supports that the sooner an individual is
restored back to the prior quality of life, the better the
chance for recovery and return to living. In this
scenario, all parties are served by doing the right
thing early on, for the right reasons, so the best
possible outcomes are achieved. In my opinion,
this would be the ideal landscape for workers' compensation.
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"If I personally could change the current landscape and create the ideal
treatment environment, it would be all parties (nurse, physician, carrier,
injured worker, and the attorney) all working together to obtain the quickest,
most effective and appropriate medical treatment to restore the individual back
to the prior quality of life." |
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Sue Bowers, RN, BSN, CCM, is the president and cofounder of Choices Case
Management.
Choices Case Management
1145 2nd Street, Ste. A #315
Brentwood, CA 94513
Phone # 925-516-3901
Fax # 925-516-3905
sbowers@choicescm.com
www.choicescm.com
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