Executive Summary

Nurse case managers are ideal collaborators in workers’ compensation cases because of their ability to facilitate, coordinate, and monitor medical care while working with a team of providers.

• Workers who became injured or ill on the job typically have feelings of losing control and might not deal well with change.

• A CM’s first goal is to prevent the worker from becoming disabled from the injury or illness.

• Although misrepresentation cases are a small percentage of workers’ comp cases, it’s important for CMs to be able to identify when this is occurring.


 

Nurse case managers are crucial to helping employees prevent, minimize, and overcome an injury or disability that occurred on the job.

“The major problem that confronts us when we’re dealing with workers’ comp is we have adults who were functioning and healthy prior to their injury or occupational illness, and then there’s some point where it interferes with their lives,” says Barbara A. DeGray, RN-BC, CRRN, vice president of case management with Managed Care Advisors of Bethesda, MD. DeGray speaks about workers’ comp management at national case management conferences.

“Workers’ compensation is the ideal setting for the application of case management techniques,” she says. “In case management, the techniques often used are facilitation and coordination of medical care, collaboration with the team, and monitoring of the progress.”

Case managers (CMs) also evaluate what happened, document everything that happened, and revise their actions as needed, she says.

“I like to remind people that those employees went to work that morning thinking they’d have a regular day and go home that night and do all their regular activities,” DeGray says.

Case managers should remember that their workers’ comp cases typically involve people dealing with change. There’s a feeling of lack of control and adults don’t like that, either, she adds.

DeGray offers these tips for initially handling a workers’ comp case:

1. A first goal is to prevent the employee from becoming disabled.

“Early on in the case we want to help them get their medical care quickly, timely, appropriately, and prevent any disability from this injury or illness,” DeGray says. “If we find they have some condition where they have to limit themselves, we want to minimize the condition.”

Case managers generally have access to the employee’s medical documentation related to the injury and can influence the direction of the employee’s recovery, she notes.

“This helps us to communicate with the treating healthcare providers,” she adds. “Within the regulations, we can help re-direct patient care away from ineffective medical care.”

An example of re-direction would be obtaining an independent medical exam, DeGray says.

“If we identify that a person is not recovering according to what is expected by industry standards, then we can assess the situation,” she explains. “If we find that the care itself is below standards, then we can help those injured workers obtain second opinions from qualified medical providers.”

2. Focus on early intervention.

In workers’ comp cases, it’s important to separate the techniques and approach that happens early in a case from later stages, DeGray says.

In this early intervention stage of a workers’ comp injury, nurse CMs get involved in helping to determine if a claim is legitimate, she says.

“The nurse case manager helps in that early stage and helps the claims staff,” she adds. “It’s up to the claims staff to determine if the injury is legitimate or not, but nurses can help.”

Early on, CMs should listen to employee patients and determine whether the person’s description of events and how he or she feels is based on fact.

“We are trained to help people, and when we come across people who may be taking advantage of the system, it does cause us a conflict: How can I help this person?” DeGray notes.

3. Learn to recognize when a person is misrepresenting their injury.

First, CMs should keep in mind that misrepresentation is just a small percent of all claims, DeGray says.

“I’ve been doing workers’ comp since 1991, and I would say that with the cases I’ve managed that misrepresentation by the injured worker is a very small percentage — under 5%,” she says.

“The challenge is that a lot of our time is spent on that 5%, so that’s why it looks so big,” DeGray says.

One strategy for determining the legitimacy of a claim involves looking for objective findings, she says.

“One of the reasons why a claim might not be legitimate is that the person’s injury was not caused by an injury at work,” DeGray explains. “In workers’ comp, we call that a causal relationship: There is something wrong with that person, but it may not have been caused by an incident at work.”

An example would be a worker who had been injured in a car accident while off work, but who then returns to work and reports that he fell down the stairs, she says.

Nurse CMs have to address the possibility of misrepresentation and even go so far as to disagree with the treating physician if they believe there is an injury misrepresentation, she adds.

“We need objective evidence of what happened to the person at work,” DeGray says. “People want to relate their injuries to work because of the financial benefit of having their bills paid 100%, and they have the benefit of having continued pay without using sick time and vacation time.”

Another misrepresentation could be when a worker lifts something at work and reports having back pain as a result of the work activity, when the truth is the person already has severe arthritis caused by a lifetime of activity, DeGray says.

“Any injury can be misrepresented, and for some workers, it’s an ongoing problem,” she says. “They might have recovered from an injury — perhaps a sprain of their ankle — but they continue to have problems with their ankle because of underlying medical conditions.”

Underlying medical conditions can be the most challenging circumstances to handle because they can make an injury worse and cause pain and limited activity, DeGray adds.

4. Develop rapport with the employee.

One way to help an employee minimize the injury is to develop a rapport with the person.

By letting the worker know that their concerns are being heard, that the CM understands their problems and wants to help them — whether or not they hire an attorney — helps build rapport, she says.

“Listen to the employee; ask what his or her concern is at this time,” she suggests. “Usually, they’re concerned about getting the medical care they need and keeping their pain at a reasonable level.”

Often, case managers can approve or authorize care without the person needing to seek higher approval, DeGray notes.

This helps build rapport, as does patient education.

“A nurse case manager can help the injured worker understand what the doctor’s instructions are and help the employee follow up on physical therapy instructions or help them get any other support they need, such as equipment or home care services or transportation or translation,” DeGray says.

“Early in the case, the employee may want to meet with an attorney. Having an attorney can be helpful, and it doesn’t mean they’ve done anything wrong,” DeGray says. “Sometimes workers feel like we want to prevent them from having an attorney.”