Workers’ Compensation Laws
by Mitzi Wortman, RNC, CCM, LNCC, CP
Nurse case managers are vital to any workers’ compensation employer or disability insurance company defendants. The injured worker or client always needs special reassurance, information and resources since he/she will be in crises over loss of function and income.
A nurse case manager can work telephonically or field visits to medical appointments. He/she poses critical questions to primary physicians in order to move the client to rapid recovery from an injury or a disability. Nurse case managers may provide the physician with records of prior disabilities, pre-existing injuries or medical conditions to assist the independent medical examiner in reaching a final and fair disability rating based on the American Medical Association Ratings Guide. This is a very important service since the benefits a worker receives are based on determination of temporary or permanent disability.
Once the primary treating physician determines a course of treatment, it may need to be reviewed (based on state law) by a nurse case manager acting as a medical utilization reviewer to ensure medical services are utilized in a timely and cost effective manner.
In cases that are considered catastrophic, when there are multiple injured body parts, or in stress-related and psychiatric claims, the use of specialists can be helpful. Nurse case managers are especially positioned to refer to local medical experts and community resources to help address the special needs and complexity of these cases. He/she may also assist the client in obtaining referral to a vocational counselor to find appropriate retraining and education if a worker cannot return to original job duties.
Case settlements with future medical awards and the ability to return to work are decided by primary treating physicians working in conjunction with a nurse case manager.
Legal nurse consultants/case managers can assist either defense or plaintiff attorneys in organizing and prioritizing medical records and treatments for presentation to the workers’ compensation board/judge.
California Senate Bill 899 was enacted in 2004. The California Workers’ Compensation Institute Study © (December 9, 2005) (www.cwci.org) found that the average utilization and the average total amount paid per claim for most major categories of California workers’ compensation medical services declined following the introduction of fee schedule changes, treatment guidelines, caps on physical therapy and chiropractic care, and other utilization management controls according to a new Institute study. The percentage of the claims involving Medicine Section procedures, Physical Therapy, Injections, and Chiropractic Manipulation all declined. The biggest reductions were in the proportion of claims using injections. This has allowed carriers’ rates to decline due to the cost savings from the workers’ comp. reforms in 2003 and 2004.
The workers’ compensation nurse case manager is a critical resource for injured workers, employers, attorneys and treating providers. He/she undoubtedly played a crucial role in implementing the reforms that led to cost containment of the medical claims and early return to work for injured employees.
