The Role of a Nurse Case Manager in a Worker’s Compensation Claim

After a workplace accident or occupational injury, an injured worker will need to attend medical appointments as part of their claim for worker’s compensation benefits. In some cases, their employer’s worker’s compensation insurance carrier will assign a nurse case manager to assist with scheduling appointments, obtaining medical treatment and prescription medications, and obtaining work restrictions. However, injured workers should beware and must fully understand the role of the nurse case manager, where their duties lie, the lack of privacy concerning discussions with the nurse case manager, and the worker’s right to ask their medical providers not to communicate with the nurse case manager.

What Is a Worker’s Compensation Nurse Case Manager, and What Do They Do?

Nurse case managers often introduce themselves by saying they are part of the claims process, or by saying they help get necessary treatment and manage return to work issues. With the worker’s permission, they may attend medical appointments and communicate with the injured worker, medical providers, and the worker’s employer about the worker’s treatment and recovery plan. At face value, the nurse case worker serves as a liaison between all parties involved in the claims process and helps keep the insurance carrier up to date on relevant medical matters, including care and treatment, diagnosis, prognosis, and the anticipated date of return to work.

In practice, however, this often means the nurse case worker acts as a “spy” - sometimes adversely - reporting to the employer and their insurance carrier everything that is discussed at medical appointments. In some cases, the nurse case manager may exert pressure to try to convince the claimant and their medical provider to follow the insurance carrier’s preferred course of action. This may include a faster return to work, fewer restrictions, less treatment, or lower permanent disability ratings.

Unfortunately, many nurse case managers are more focused on the preferences of their contractor (the employer and/or worker’s compensation insurance carrier) than on the uninfluenced medical decisions of treating providers or the worker’s compensation benefits you entitled to under your treating providers’ uninfluenced opinions. They can influence medical providers, suggest different or less medical treatment than treating providers, and minimize claims.

Your Rights as an Injured Worker

If you have a worker’s compensation injury and have a nurse case manager assigned to your claim, you should be asking yourself questions about the nurse case manager’s role and your legal obligations to work with them. While nurse case managers can sometimes be helpful and sympathetic - particularly when an injured worker is indeed receiving suboptimal medical care or the injury is severe - their involvement can be detrimental to the long-term success of your claim.

The main federal medical privacy law (HIPAA) does not apply to claims for worker’s compensation benefits. However, under other privacy laws and rules, injured workers have the right to ask medical providers not to communicate with the nurse case manager. But doing so risks upsetting the carrier’s claims adjuster, which could lead to an earlier denial of benefits than would have otherwise occurred.

Can You Refuse a Nurse Case Manager?

Injured workers have rights when dealing with a nurse case manager. Understanding these rights helps you maintain control over your claim for worker’s compensation benefits and the information shared about your case.

• You have the right to refuse permission for the nurse case manager to join you during medical appointments. While HIPAA does not apply to claims for worker’s compensation benefits, other medical privacy laws and rules do. To ensure optimal medical care if you believe the nurse case manager is becoming adverse, you have the ability to discuss your situation with your medical provider without feeling you are being watched.
• You can tell the nurse case manager to stop talking to you and your medical providers. If you tell the nurse case manager to stop contacting you, they should comply. While you cannot stop the carrier’s claims adjuster from contacting your medical providers in writing, there is no provision in Wisconsin’s worker’s compensation law allowing nurse case managers to communicate verbally or in written format with your medical providers.
• You can ask your medical providers not to discuss your claim with the nurse case manager. Your medical providers are not required to communicate with the nurse case manager, and if you ask them not to, most will likely honor your request.

Tips for Preventing Interference from a Nurse Case Manager

If a nurse case manager is assigned to your claim, you have the right to make your preferences known and to ask them not to interfere with your care and treatment.

• Politely inform the nurse case manager that you prefer that they not attend your medical appointments.
• Inform your doctor and other medical providers that you do not want the nurse case manager involved and ask your care team not to discuss your claim with them.
• Document your request for medical privacy and minimal involvement from the nurse case manager.
• Contact your employer and their worker’s compensation insurance carrier to express your concerns and why you believe involving a nurse case manager is unnecessary or will harm your claim.
• Again, keep in mind these steps carry the risk that the claims adjuster may obtain a report from an insurance-friendly doctor opposing your doctors’ opinions, i.e. a claim denial, earlier in your case than if you had allowed the nurse case manager unfettered access. You need to weigh this against the opposite risk: Allowing the nurse case manager unfettered access may result in them pressuring your doctors toward the carrier’s preferred course of action, or minimizing the benefits you would have been entitled to if the nurse case manager was not involved.

The team of worker’s compensation attorneys at Kingree Law Firm can advise you on the nurse case manager’s involvement in your specific situation if you become a client.

How an Experienced Worker’s Compensation Attorney at Kingree Law Firm Can Help

Kingree Law Firm is a premier worker’s compensation law firm in Wisconsin. Our team of skilled and experienced worker’s compensation attorneys exclusively represents injured workers in claims for worker’s compensation benefits. We primarily represent injured workers outside the Milwaukee area and have earned a reputation as one of the top worker’s compensation law firms in the state.

Contact Kingree Law Firm Today

If you experienced a workplace accident or suffered an occupational injury that caused significant lost time from work, permanent disability, permanent wage loss, or if your claim for worker’s compensation benefits was denied, contact Kingree Law Firm today to schedule an appointment to discuss your situation and how we can assist you.