Case managers advocate rather than spy

Know when to remove yourself from sensitive cases

By Susan Gilpin, JD
Mindy Owen, RN, CRRN, CCM
Commission for Case Manager Certification
Rolling Meadows, IL

Some insurance companies often use surveillance techniques in an attempt to discover fraud in workers’ compensation and disability cases. When cameras are brought in, case managers should step out in order to avoid ethical dilemmas. But clearly this is easier said than done.

The Code of Professional Conduct, developed by the Commission for Case Manager Certification (CCMC) in Rolling Meadows, IL, describes the case manager/client relationship as a fiduciary relationship. In other words, clients are vulnerable and trust that the case manager will promote their best interests. Case managers are advocates for patients. The bottom line is that case managers must constantly base decisions on their patient’s benefit and how that benefit can be obtained within the system.

  • Ethics case study: A workers’ compensation case manager is asked by a payer to review a surveillance tape and report her impressions of the client under surveillance. The case manager is a paid employee of the payer. How can the case manager fulfill a fiduciary obligation to the client without jeopardizing her job?
  • Discussion: There are several key steps case managers should take in weighing any professional ethical dilemma:

— identification of issues;

— assessment of components;

— decision making;

— implantation;

— evaluation.

The life of a case manager is extremely difficult due to the multiple and often competing obligations, which pit the case manager’s client against his or her employer. Case managers must comply with all applicable laws and codes of ethics, which come into play in each situation. Some of the issues the case manager in this case must confront are:

  • the case manager’s fiduciary responsibility to the individual receiving services;
  • the case manager’s obligation to his or her employer/payer;
  • confidentiality issues raised by the Health Insurance Portability Accountability Act, her state practice act, her professional standards of practice, and her professional code of ethics.

In most cases, one of the case manager’s best defenses against ethical and legal dilemmas is to fully inform the patient client up front about his or her options, the coverage of the plan, choices for going outside the plan and, in workers’ comp cases especially, the relationship between the case manager and the payer as well as clear identification of all the parties to whom the case manager must report findings.

Making an ethical decision is easier if case managers establish a clear understanding at the very onset of the client’s wishes and needs and the case manager’s role and responsibilities. It is absolutely critical that case managers represent themselves honestly. The case manager must always make it clear to their clients, verbally and in writing, what the case manager can and cannot do.

This includes fully informing clients if the people who provide their benefits employ you. If the client seems to have a limited understanding of what that means, repeat yourself often. It also is good to document this information in writing so that the client has a copy for his or her records as well.

Ethical decision making also is easier if the case manager’s job description accurately reflects the principles outlined in the CCMC Code of Professional Conduct. In a perfect world, the case manager’s employer would have standards, which also contain these principles, so that the case manager is not placed in the position of having to jeopardize his or her employment in order to do what is right for a client.

If you have not recently reviewed your job description, pull it out and read it critically. Does it list activities in which you will not participate due to conflict of interest with applicable laws or your professional standards of practice or code of ethics?

Surveillance is a common practice in the workers’ compensation arena, but it places the case manager in very muddy waters. In a best-case scenario, a case manager could remove him- or herself from any case in which surveillance occurs on ethical grounds and remain employed.

While surveillance may be common practice for other professions, it is not usually part of the role of a case manager. However, as with any piece of information that you may process in order to deliver services to an individual, it is important that you are objective in your assessment and reporting.

Make sure that any documentation you create after reviewing a surveillance tape clearly reflects just what was portrayed on the tape and does not include any subjective conclusions. In addition, you must be clear in your written report to document the limits of your expertise and never go beyond those limits in an effort to curry favor with the employer/payer. And, as always, avoid stating your own opinion.