Determine your allegiance prior to accepting job

Reconciling advocacy and transparency

By Leah E. Perry
Media Relations Coordinator
Commission for Case Manager Certification
Rolling Meadows, IL

As a case manager, you are well accustomed to working in a number of roles. However, those roles can become complex when your patient advocate role does not mesh with the obligations you have to your employer.

Case in point: You discover that one of your patients is eligible for benefits under the Americans with Disabilities Act. The sticking point — the employer for both you and the patient will be out several more thousands of dollars. To whom is your allegiance, and how do you avoid getting caught in the crosshairs?

The answers are not so easy. "The bottom line is that you are juggling two paradigms — the advocacy one, which is certainly the more traditional one, vs. a transparency paradigm," notes John Banja, PhD, associate professor of clinical ethics at Emory University in Atlanta and a commissioner with the Commission for Case Manager Certification (CCMC) in Rolling Meadows, IL.

"Certified case managers are accountable to the Standards of Practice, which say that one of a case manager’s major job components is that of an advocacy role," adds Mindy Owen, RN, CRRN, CCM, a Coral Springs, FL, health care consultant and chair of the CCMC ethics committee. "So even though you get your paycheck from that employer, it’s imperative that you walk that tightrope and focus on your responsibilities and accountability in your advocacy role."

"There are certainly a lot of gray areas, but the standards give you a road map to follow and present to your employer to say, this is who I am, this is what I do, and in this role I must bring to the patient relevant information. I am going to be an advocate for that patient.’ If the employer has a problem with that, then you as a certified case manager must evaluate if this is really a place where you should be working," Owen says.

"If it is a job you need or wish to continue, then perhaps it is best to approach the position not as a case manager but as a consultant instead. Agree with your employer that you are not in a case management role at all. Redefine and retitle the position and then proceed within your new duties.

Banja and Owen offered the following suggestions to help case managers grappling with this moral issue:

• Abide by the transparency model. In this model, case managers make their allegiances transparent or known to their patients prior to working the case. "You are telling your patient, If you are going to consent to my performing case management services for you, you need to know how I understand my allegiances and how any information that you give to me is going to be used. For example, if you tell me you were inebriated when you got to work that day and that’s why you fell off the ladder, that might work against you."

"If the case manager feels that it is morally appropriate to reveal to the claimant’s employer any information that might negatively affect the employee’s eligibility for benefits or his or her right to make a claim, the case manager needs to provide the patient with that information," says Banja.

"If case managers are reluctant to do that, that says something about the fact they are double agents and that they are willing to allow a certain amount of mendacity or deceitfulness to punctuate their relationship with that client, and that’s no good," he adds.

• Take the "morality-by-contract" approach. Banja calls this strategy the "contractualist approach" or morality by contract. You can avoid gray areas simply by evaluating what the contract says. "If the contract stipulates conditions that are acceptable and you sign on the bottom line, then you are obligated to perform your duties within those stipulations," Banja notes.

To help clarify, ask yourself this question: Are you a steward of the resources of the third-party payer? Whether the contract is a workers’ comp or a health insurance contract, you will "obviously develop a care plan within the limitations of that contract, so essentially you are a steward, but go a step further and ask a more fundamental question — "Is this client eligible for these benefits to begin with? Does the case manager stand within the benefit structure of what is owed to that particular claimant or does in fact she not only stand in it, but also stand outside of it [so] as to make determinations as to whether this claimant can enter into that receipt of benefits?"

Do not attempt to determine a patient’s benefit eligibility. The reason, Banja asserts, is simply that case managers are not trained to do eligibility determination work. "Case managers primarily are secured to manage an individual’s care or case. They are advocates for the patient, the claimant, they are trained to do that and their training is bounded by making decisions that are going to secure the best services for this particular claimant per the benefits that he or she has available," he says. "Therefore, this kind of advocacy paradigm says overwhelmingly the case manager’s first and foremost duty is to the claimant, similar to the lawyer-client relationship."

• Discuss specifics of your advocacy role prior to accepting employment. "It is perfectly appropriate to do this, and the case manager is accountable to have that discussion in the interview process as to how the employer sees the case manager’s role," says Owen. "You need to get a clear understanding from the employer as to whether they have a bent or philosophy towards advocacy or one more toward an antagonistic relationship. It is the case manager’s responsibility to get this role clarified.

"As case managers, we are pulled in many directions within and outside of the practice setting we find ourselves in," explains Owen, and will consistently face ethical dilemmas as they continue to work for employers and with clients needing their expertise and assistance. "Remembering to do the right thing at the right time and for the right reasons will certainly help guide case managers in serving the public in a professional and ethical manner."