June 19, 2019

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. [Read more…]

Case Study: Back Injuries and Workers Compensation

The prevalence of on-the-job back injuries

According to government statistics,  nearly 20% of all the work-related injuries involve back injuries and back pain, especially lower the back area.   The cost of these work injuries continues to soar – currently estimates put the cost of treatment and lost productivity at nearly $20 billion annually.   Not surprisingly many of the cases I see involve some form of back injury – ranging from cervical (neck) damage to lumbar and thoracic (mid to lower back) injuries.   In my experience, quick diagnosis and treatment can greatly improve the chances of a more complete recovery.

General causes of back injuries

Back injuries can result from numerous causes including:

  • Heavy lifting
  • Remaining in the same position for too long and too often
  • Repetitious activities and movements
  • Stressful lifestyles

Back braces and modified lifting techniques can help but not prevent back injuries.

The back injury case of Mr. S

Mr. S worked for a company that owned several large trucks.   The company was selling several of its trucks and Mr. S’s supervisor directed him to show the truck to a potential customer. Mr. S was attempting to push open the hood of the truck when the hood (weighing 300 lbs.) detached and fell on him, pinning him to the floor.  Mr. S  began experiencing pain in his lower back as well as radiating pain in his leg.

This accident was witnessed by both the potential truck buyer and Mr. S’s supervisor, who instructed Mr. S to go to one of the posted panel doctors.   Upon arriving at the doctor’s office, Mr. S noted that the line of patients was out the door and since he did not want to sit around and wait, he decided to return to work and took pain medication before returning to the job. Mr. S continued working for the next 4 months, relying on over the counter pain pills to reduce his pain.  At no point did he ever actually meet with a doctor.

Around 4 months later, Mr. S again injured his back while working on a truck.  This time, he felt a definite “pop” and his legs went numb.  The supervisor again sent Mr. S to a  posted panel doctor who took Mr. S off work and began conservative treatment (prescription pain pills and physical therapy)  When Ms. S was unable to perform the exercises during physical therapy, the panel doctor ordered an MRI.  The MRI revealed several bulging discs as well as 2 herniations with impingement on the spinal cord.

The panel doctor then referred Mr. S to an orthopedist for surgery.   Mr. S was not impressed with the surgeon and he emailed me with his story to ask if he had any options.   I suggested to him that if I was dealing with the same injury I would want to be evaluated by a specific neurosurgeon, and I also explained what Mr. S could expect in terms of rehab and case settlement.  At that point, Mr. S retained me to serve as his lawyer.

Once I was retained I contacted the insurance adjuster and suggested that we agree that Mr. S should be seen by a neurosurgeon who I know to be very capable.  The adjuster agreed (to my surprise) and my client underwent a multi-level fusion, which my client underwent.

There was one other interesting twist to this case – at the time my client was seen by the original panel doctor for the second time, the adjuster assigned a nurse case manager to assist with my client’s care.  For those of you who are not familiar with the role of the nurse case manager, she is a nurse who works on behalf of the insurance company to facilitate care.  Sometimes, nurse case managers can be helpful in cutting through red tape – such as getting diagnostic reports like MRI films to a doctor. In other instances, the nurse case manager can interfere with treatment by advocating on behalf of the insurance company – for example I have seen cases where a nurse case manager attempted to influence a treating doctor to return a claimant to work too early.

Years ago, the insurance company had a right to assign a nurse case manager.  Under current law that right exists only in catastrophic cases.  Otherwise the claimant (usually through counsel) can terminate the involvement of the nurse case manager.

In this case, we had to do just that.  The nurse case manager was attending my client’s medical exams and she was pressuring the surgeon to speed up the rehabilitation process.  I felt that her motivation and value were in question and I advised the adjuster that we no longer needed her services.

The Nurse Case Manager – Who is She and Does She Belong on Your Case

[mc id=”175″ type=”audio”]Jodi discusses the role of the nurse case manager and when it makes sense to terminate her involvement[/mc]One of the lesser known players used by Georgia workers’ comp insurers is the nurse case manager. In the past, insurers could assign nurse case managers to every claim. Now, claimants and their lawyers can terminate the involvement of nurse case managers, except in the instance of catastrophic injury cases. Who is the nurse case manager and what does she do? In this short audio report, I explain how insurance companies sometimes use nurse case managers to try and influence treating doctors and I discuss a recent case in which I pulled the plug on a nurse case manager’s involvement.