September 17, 2014

Insurance Adjuster Attempts to Use Nurse Case Manager Against Injured Worker’s Interests

illegal actions by workers compensation adjusterThis past July, I discussed on this blog issues related to the participation of a nurse case manager in a Georgia Workers’ Compensation claim.   In that post I pointed out that insurance adjusters sometimes assign a nurse case manager to a particular claim.  The nurse case manager is not an adjuster, and they do not deal with issues related to wage benefits.  Instead, they deal with the medical component of your case only and a nurse case manager can be helpful in setting up medical appointments, coordinating transportation to and from doctor’s visits and working out issues with prescriptions.

Issues arise when the nurse case manager tries to influence your doctor about signing off on a return to work release or suggesting to the doctor that he include in his reports statements which say that your pain has subsided and that you are doing better.  Some nurse case managers even try to influence the drug prescriptions written by the doctor.  Others appear at each one of your appointments and try to stay in the room when your doctor examines you.  You have the absolute right, by the way, to insist that your nurse case manager step outside during your examination and conversations with your doctor.

Other issues arise when the insurance adjuster uses the presence of the nurse case manager to damage the injured claimant’s claim and to improperly influence medical treatment.

While I have seen instances where the nurse case manager truly cares about the health and welfare of the injured worker, more often than not the nurse case manager serves as the eyes and the ears of the insurance adjuster, with the primary goal of minimizing cost and to the insurance company.

I generally take a very cautious view towards nurse case managers and I will not hesitate to demand their removal from your case, as Georgia law allows a claimant and his attorney to reject the participation of a nurse case manager. I would, for example, most likely terminate the participation of a nurse case manager who wanted to stay the room during my client’s examination with his doctor.

Case Study: Insurance Adjuster Attempts to Use Nurse Case Manger Improperly

Recently, I represented an injury worker in a case (which we have now settled) where the insurance adjuster hired a nurse case manager because my client’s injury was complicated and because the injured worker decided to move from Georgia to another state.  Because of these factors and because my client needed specialty care, I agreed to the participation of a nurse case manager for the purpose of coordinating doctor’s appointments out of state, and to help arrange for physical therapy and rehabilitation.

As permitted by Georgia law, I asked the adjuster for copies of the nurse case manager’s notes as well as the memos and letters issued by the adjuster to the nurse case manager.   Here is the actual text of a memo written by the adjuster to the nurse case manager:

Nurse X…” our main concern is to have the claimant undergo the surgery, if Dr A agrees that it is indicated, and to get her released to full duty and maximum medical improvement status ASAP. We are continuing to pay her temporary total disability benefits. Please note she is represented by an attorney.  If you receive any requests for Attorney Ginsberg, do not comply but forward the request to me for approval. I would ask that you send your status reports  directly to me only and I will determine what information should be forwarded to (injured workers) attorney.

As you can see from this memo, the adjuster is telling the nurse case manager not to cooperate with me and that the adjuster intends to withhold information from me!

The nurse case manager (to her credit) responded to the adjuster and advised the adjuster that Georgia law obligated her to cooperate with me.  Here is what the adjuster said next:

I am aware of the statutory requirements in Georgia and I do not have a problem with your complying [with the law] in providing Attorney Ginsberg with all correspondence.  What I do not is any ex parte communications with Attorney Ginsberg. I want a copy of ALL emails, faxes and letters to her. I have had a problem with Attorney Ginsberg in the past with her over involvement with this claim and her attempts to direct  how this claim is managed.

Now, we have the adjuster continuing her improper and unethical behavior by re-stating that the nurse case manager should not respond to correspondence directly from me.

Once I saw these memos, I immediately wrote the adjuster to advise him in no uncertain terms that his actions in trying to deny me access to the nurse case manager’s notes was improper under Georgia workers’ compensation law.   I also advised the adjuster that if this case went to a hearing, I intended to put him on the stand to explain his actions to a workers’  compensation judge.

After receiving my email the adjuster did not respond to me but turned this case over to an insurance company lawyer.   The lawyer cooperated fully with me and agreed to a very favorable settlement, which I suspect had something to do with my discovery the illegal actions of the adjuster.

This kind of nonsense goes on all the time and if you or your attorney is not paying attention you will find yourself at a disadvantage in terms of access to medical and other case records.  I will, by the way, take as a compliment the adjuster’s complaints about me and my efforts to “control” the management of my client’s claim.  Georgia workers’ compensation is an adversarial system and I will not allow an insurance adjuster (or a nurse case manager) to get away with anything that damages my client’s case.

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For over 15 years, I have represented injured workers in claims filed under the Georgia workers' compensation system. I hope that you find this blog helpful in learning how the Georgia workers' compensation system works and I invite you to call or email if you need more information. --Jodi Brenner Ginsberg

Comments

  1. I think this article gives nurse case managers a bad name, and for no just reason. I have never dealt with an adjuster that would do anything illegal or unjust. It’s articles like this that make my job harder and puts workers compensation case management professionals in a bad light. It is hard enough to do our job when our claimants do not trust our intentions, and they are not as the article implies. Not at all. I would never jepordize my professional reputation or my ethical standards such as this example notes. The majority of adjusters and nurse case managers are honest and true to the advocacy of the injured worker.

  2. Charles S. says:

    I have had 4 workers Compensation cases in about 30 years of work experience. Each time was a true accident and my injuries are real and caused my final disabilities. Each case I hired an attorney. I will advise you to hire the best WC lawyer you can find IF your injury causes you some % disability or lingering problems or may cause problems in the future even if you are returning to your job. WHY? Because the company usually has an insurance company who handles all injuries and they will not give you any treatment they do not absolutely have to give. They will attempt to make any problem you have appear as if it is pre-existing, minimal or nonexistent. They will go the cheapest route in care no matter the severity of your problem and they will cut, off benefits at the drop of a hat.
    I advise anyone who suffers a severe injury on the job to hire an attorney. He will handle the final settlement of your claim and see that you get long term benefits and settle any percentage of permanent disability you may have. You are entitled to compensation for you injury if it causes permanent damage. I have found that they do NOT make sure that you receive all the best medical care. They rather sit back and wait until the doctor says you have reached Maximum Medical improvement and then make the big money decisions on how much money you will get. (They will get 25% plus expenses in most states.) They will generally not get very involved in the everyday medical part UNLESS it is obvious that the insurance is boldly violating the law. YOU and your wife or some other family member MUST become experts on the workers comp law in your state and fight tooth and toenail for what medical your law says you are entitled to. I repeat, know the law of your state or you will not be able to fight the insurance company.
    IF your insurance company assigns an RN case manager this is the best way to handle her. DO NOT TELL HER ANYTHING that you don’t have to. Don’t say anything other that what you have to because she will use anything you say against you. The RN case manager is NOT for your benefit. She is gathering what info she can to discredit you and make the doctor do what the insurance companies medical team says they are going to do. YES, every insurance company gets your medical records and goes over every part to see if they can show your injury is not serious or does not exist. They will low ball everything the doctor wants to do and the RN will, as she did in two of my cases, tell the doctor how and with how much effort he will treat you. She will manipulate the doctors statements to get him to say what the insurance company wants and get you as little treatment as possible. They do not care if your injury is minor or life and death it is the MONEY they worry about. As a matter of fact if you died from your injury it would be the cheap way for them. They would pay the death benefit and be through. THE INS. CO. is NOT your friend. DO NOT sign anything without an attorney if you do you will lose. Remember that case manager is not on your side and anything you say or do will mean trouble to you because she will use any little statement or anything she sees against you.

  3. Bissontz – I am not saying that every nurse case manager has bad intentions but the way the system is set up, nurse case managers report to adjusters and they are paid by insurance companies. At the very least a nurse case manager has divided loyalties and often more loyalty to the insurance company. I stand by my opinion.

  4. Lissenelle says:

    @Bissontz:
    Dear Bissontz:
    I strongly agree with your response to this unfair and very biased opinon regarding case managers. In over fifteen years of case management I have never wittnessed or participated in anything that would be unethical, illegal, or otherwise and do not know any case manager who would. We are nurses first, professionals who take an oath to provide the very best care for a client, which is undetermined by who our payor source is. It is always in the client’s best interest and to everyone elses benefit to obtain medical treatment with the very best and most qualified health care provider!! We do not seek out “bottom basement” physicians. We do not facilitate a premature RTW, knowing that it will only create future problems for everyone in the longrun. We do not instruct physicians how to document or when they should release a client. We care for the injured worker and want to see them return to a productive work environment only when and if they are able. Modified duty positions are coordianted only with the approval of the treating physician and it must be documented in his dictation. I am appalled at this attorney’s accusations torwards case managers. It is offensive at the very least. I can not count the number of clients who, attorney represented, call me after a case has settled and complain because the attorney appeared to care so much in the begining. However, once settled and the attorney received a portion of the settlement plus cost,the attorney would not return their calls or have anything to do with them. I worked for attorneys a number of years before becoming a nurse and can say with absolute certainty that case management is such an honorable and noble profession, one that I am so proud to be a part of. We are a client advocates who want to them to obtain their vey best post-injury potential and nothing else. And FYI we do not just set up appointments & coordiante “trips to the doctor”. We met with the physicians, threapist, review medical and PT notes, coordinate RTW, coordinate medical equipment, home health, and so much more in an effort to make sure that the client is progressing and receives the highest quality of care available.

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