Avoid common ethics violations while keeping patients' best interests in mind

Put your feelings, monetary considerations aside

When it comes to being an effective, professional — and ethical — case manager, it all boils down to being a good advocate for your clients, John Banja, PhD, asserts.

The role of case managers is to advocate for their clients and to keep their best interests in mind, even if the client is difficult to deal with, or the case manager doesn't like him or her, or their boss wants them to do things another way, adds Banja, professor, department of rehabilitation medicine, medical ethicist, the Center for Ethics at Emory University in Atlanta.

Banja served on the Commission for Case Management Certification (CCMC) for six years and was a member of the ethics subcommittee for the commission. In the latter role, he reviewed ethics complaints about case managers received by the CCMC, many of which were in workers' compensation cases when a personal injury attorney was involved.

"In the majority of cases, the personal injury attorney came across material in the case management documentation and reports that would not reflect well on the professionalism of the case manager," he adds.

Banja emphasizes that the vast majority of case managers do not commit ethics violations.

"Overwhelmingly, case managers are good-hearted, well-educated professionals who advocate intensely for their patients, but there are about 100,000 people out there who call themselves case managers and not all of them are that careful, professional, and discreet," he adds.

Standards of Practice guiding principle

Case managers who are charged with ethics violations can face a reprimand, probation, suspension from CCM certification, or revocation of CCM certification.

But regardless of whether they have achieved CCM certification, case managers should keep the CCMC's Standards of Practice in mind as they go about their work, as guiding principles, Banja says.

"If a case manager is ever involved with a lawsuit, the CCMC standards would be where the court would look to determine ethical behavior for case managers," he points out.

The first responsibility of case managers is to advocate for their clients and it's when they forget about this that ethical violations often occur, Banja says.

In many of the ethics violation cases that came before the CCMC committee, the case managers were frustrated and discouraged from dealing with difficult clients and articulated their frustration in their reports, Banja says.

He cited hypothetical examples of cases that were similar to those that came before the commission: "The injured worker did not attend therapy because it was the first day of hunting season." Or, "The injured worker was clearly exaggerating his pain." Or, "The client's wife is obnoxious and argumentative."

Case managers should guard against letting their personal feelings and frustrations interfere with their objectivity when they write their reports. They especially shouldn't put anything in a written report that would be embarrassing if the client read it, Banja advises.

"Most of the time, nurses, doctors, and case managers are not going to have ethical dilemmas or problems if things go well," he says.

Patients who make case managers uncomfortable or anxious or who exhibit threatening or quirky behavior are the most challenging ones. Ethical lapses typically occur when the case manager has a difficult patient, treatment doesn't go well, or the patient and the case manager simply don't get along, Banja points out.

Objectivity compulsory

He advises case managers to maintain objectivity in their relationship with clients and to avoid imposing their own values on them. For instance, don't write in the record that the patient says he has financial problems but continues to buy cigarettes or to comment on the client's personal appearance, assuming it has no bearing on the client's care program.

"It's easy to be a good case manager with a patient you like and who likes you, who is compliant and the treatment plan works. When case managers are confronted with a client they don't like, they should be extra careful and extra reflective not to let their feelings interfere with doing their best for the patient," he says.

Notes to the payer, physician, or therapist that contain biased language can influence the opinion of the other clinician, Banja points out.

Ethical violations also occur when case managers overstep their authority and make determinations, such as medical necessity, that only a physician can make, Banja says. For instance, a case manager should not write, "I will not authorize an MRI; the client doesn't need one," or "Physical therapy is not indicated after this procedure."

"Experienced case managers have seen a lot of maladies, diseases, and disabilities and they may be totally right, but only physicians can determine medical necessity and case managers should not write anything in the record that indicates they are practicing outside the boundaries of their competence, training, and professional experience," he adds.

Case managers should be objective when they write their reports and keep in mind that the physician calls the shots on medical necessity. "Case managers may call the medical director's attention to certain things but they have to do it in a way that does not bias the mind of the person making medical necessity determination," he says.

When a case manager's actions are solely geared at trying to save his or her employer money but the patient reasonably needs the covered benefit, it's a flagrant violation of the standard of advocacy, Banja says.

"For instance, particularly egregious ethics violation occurs when a workers' compensation case manager steers a client to a particular physician because she knows that the physician will likely side with the payer in saying that the patient is ready to go back to work or doesn't need a particular treatment, whereas most other physicians would reasonably and loudly disagree," Banja says.

"Some physicians will almost write the treatment plan according to what the payer would like to pay. In these cases, the case manager is advocating for his or her boss, the payer, and not the patient. Ultimately, case management ethics is all about the advocacy," he says.

Constantly ask yourself if you are doing what you are doing for the sake of the patient or for other reasons. Don't let saving money for your employer interfere with your professionalism and patient advocacy, he advises.

Case managers should be scrupulous when it comes to disclosing or entering information on medical records so as not to violate HIPAA, Banja says.

John Banja's no-brainer test of ethical behavior

Ask yourself three questions:

  • Is it legal?
  • Would my mother approve?
  • What if my behavior was described on the front page of tomorrow's New York Times?

When there is a request for medical records, the recipient should get only documentation that is relevant to the issue at hand and not the whole medical record.

Make sure you get the client's written permission to share confidential information to a third party.

Case managers have an ethical obligation to be as knowledgeable as they can be so they can identify and coordinate all the resources that their clients need.

"Continuing education is part of a case manager's ethical responsibility. They have an obligation to read the literature and go to conferences so they'll have all the knowledge they need to manage their clients' care," he says.