Dealing with Nurse Case Managers in NC Workers’ Compensation Claims

Being injured on the job and going through a workers’ compensation claim can be challenging. The injured worker has to be concerned with getting his/ her workers’ compensation checks, filing the correct forms with the North Carolina Industrial Commission, dealing with doctor visits, and other various issues. Therefore, it might seem like a relief to the injured worker when the insurance company assigns a nurse case manager to “help” the injured worker. In some situations, nurse case managers do in fact help the injured worker obtain medical care and prescriptions. Unfortunately, many times the nurse case manager does not act in the injured workers’ best interest and can be merely a tool used by the insurance company to interfere with an injured worker’s medical care.

At The Elmore and Smith Law Firm, PC, our Asheville workers’ compensation lawyers can help you understand your rights and your options if you are hurt at work. If you have questions about workers’ compensation benefits, please call our office for a free consultation.

Nurse Case Managers: What You Need to Know

In a workers’ compensation case, the workers’ compensation insurance company has the right to assign a nurse case manager to help facilitate an injured workers’ care. The injured worker cannot refuse to cooperate with the nurse case manager if he/ she does not want to jeopardize their workers’ compensation benefits. Theoretically, the nurse case manager is there to facilitate the medical care of the injured worker including scheduling medical care and making certain that prescriptions are filled. However, insurance companies do not usually spend money on case managers unless it saves them money in the long run. Unethical nurse case managers who seek to please their employers can attempt to discourage doctors from prescribing expensive treatment or providing an injured worker strong work restriction, or they may otherwise place their “thumb on the scale” in an injured worker’s medical care.

Rules Nurse Case Managers Are Required to Follow

In order to protect injured workers, the NC Industrial Commission requires nurse case managers to follow specific rules. A copy of those rules can be found here:

Some of those rules include:

1. The injured workers’ right to a private examination every time with their doctor. The nurse case manager is required to inform the injured worker of their right to a private examination with their doctor. This protection is, in this attorney’s opinion, the most important protection to an injured worker. The injured worker should ALWAYS meet with their doctor outside of the presence of the nurse case manager so that the visit can be free from any undue influence.  This rule is also the most common rule broken by unethical nurse case managers. The unethical nurse case manager will often show up at a doctor’s office, introduce themselves to the injured worker, and when the injured worker is called in for their visit, they will stride into the examination room with the injured worker pretending as if this action is completely normal. It is not! It is only the biggest red flag of the nurse case manager’s true intentions of trampling the injured workers’ rights and to influence his/ her medical care.
2. The injured workers’ right to be present when the nurse case manager speaks to their doctor. After the private examination, the nurse case manager can meet the doctor to ask for clarifications in the doctor’s orders. The nurse case manager cannot make suggestions or otherwise attempt to influence the doctor’s opinions. The injured worker has the right to be present during this discussion and should object if the nurse case manager is stepping out of bounds. It is also a good idea to record these meetings with a cell phone or other device.
3. The injured workers’ right to all reports generated by the nurse case manager. The rules require the nurse case manager to generate reports at least monthly regarding their case. This attorney has seen nurse case managers generate reports, but then only give them to the workers’ compensation insurance adjuster. This action, too, is a violation of the rules and a big “red flag.”
4. The injured workers’ right to receive a copy of the rules for rehabilitation professionals. A nurse case manager must give an injured worker the rules the nurse case manager must abide by at the start of every case. If they do not do this, this is another “red flag,” indicating that the nurse case manager does not want the injured worker to know of their rights under workers’ compensation laws.

If an injured worker has a nurse case manager that is not following the rules, they can report their behavior to the N.C. Industrial Commission, which governs all North Carolina workers’ compensation cases, at (800) 688-8349. An experienced workers’ compensation attorney can also protect an injured worker from abuse at the hands of the workers’ compensation insurance company and/or the nurse case manager.

Need help with a workers’ compensation claim? Call our Asheville workers’ compensation lawyers directly to request more information or to schedule a free consultation.