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The Role of Nurse Case Managers in North Carolina and Virginia Worker’s Compensation Cases

The title sounds good. A nice nurse case manager (NCM) will help you communicate with your doctors. They’ll help you get to your appointments and look out for your best interests. But don’t be fooled. The nurse case manager is hired by the employer’s insurance company to help you return to work – often before you’re really ready.

Nurse case managers help set up appointments with your doctors, psychologists, and therapists. They keep notes on your appointments and progress including if you missed or were late for appointments. They meet with your doctors, sometimes while you are meeting with your doctor, other times after ou have left the appointment.

Nurse case managers report back to the insurance company. They are really the “eyes and ears” of the insurance company insofar as your medical treatment is concerned and is part of what I call the trinity of “defense professionals” that are typically employed to try and derail your case. If the insurer thinks that you aren’t following your doctor’s treatment plan for you, they can seek to terminate your rights to both wage loss benefits and payments for medical treatments.

The better nurse case mangers do help in a lot of ways

  • They help patients make appointments with the right health care providers
  • They usually attend the medical appointment with you
  • They help you get the transportation you need if you can’t drive or get to the medical providers’ office.
  • They will keep track of your diagnosis, prognosis, treatments, and medical issues
  • A good nurse case manager can sometimes even advocate for treatments that your doctor recommends when your insurance company may balk at paying for expensive treatments.

Concerns injured workers should have about nurse case managers

That being said, we have found that that “good” nurse case managers are a rare occurrence. Usually, spurred on by the insurance company, the nurse case manager’s aim is to encourage your doctor to release you to return to work. While employees generally do want to return to work where they can get full pay, enjoy doing a job well, and enjoy the companionship of workers – employees should know they have the right to return to work when they’re healthy and not before.

A nurse case manager means that you will lose some privacy over the way you handle your recovery. For many workers, the pain and anxiety of the recovery process can be unbearable. It’s not comfortable for many workers to have to share intimate and personal information with anyone who is not fighting for them 100 %. Many people are afraid to admit how much they really hurt. With their health providers, they should be more open – but with a nurse case manager, they may not fully say all their complaints – which can hurt their case.

Nurse case managers are informed of your medical history, your disability, what caused the accident, the work restrictions you have, and other personal sensitive information.

Losing your privacy pales in comparison to some of the other things nurses can do to directly affect your benefits.

  • The nurse case manager may try to get your doctor to say you are healthy and don’t need any more medical treatments
  • The nurse case manager may question (and pressure) the doctor about why you still need treatments
  • He or she may pressure the doctor to release you to light duty, meaning some type of work, even something not really viable such as a 2 lbs lifting restriction, which enables the employer to put you into a “dead end” job and on a path to being fired, or gets your benefits cut off if you are not under an Award
  • She/he may question your doctor as to why work restrictions are still needed – why you can’t work at full duty
  • Will seek to get you or the doctor to say you’re not really hurting all that much
  • Leave out important oral and physical details when reporting back to the insurance carrier for the employer

Your rights when a nurse case manager is assigned to your workers’ compensation claim

Employees should always speak with an experienced work injury lawyer as soon as a nurse case manager asks to be involved in your claim. The attorney will explain what the nurse case manager can and can’t do. The attorney will explain that the nurse case manager does NOT have the right to be in the examining room with you the entire time and that you have the right to speak with your physician in private, so you don’t hesitate to say everything that’s wrong with you.

Even if the nurse case manager can directly help, for example  – help you move because you’re not mobile due to leg or feet injuries –  once you are in the doctor’s examining room, you have the right to ask the nurse case manager to sit in the waiting room, assuming the doctor is agreeable.  

Many workers have significant injuries that cause additional problems that are not obviously related to the original injury. For instance, workers with severe spinal injuries may be embarrassed to admit in front of the nurse case manager that they are experiencing incontinence or erectile dysfunction—and the worker may not realize that these issues are directly related to their spinal injuries. The physician needs to understand all your physical pains, issues, and emotional anxieties to treat you properly.

In addition, some workers hate to admit they can’t do their job. They may try to do more than they can to get back to work. Doctors need to conduct a full examination to understand if you can do your prior job. They need to conduct tests to analyze what restrictions (such as not lifting more than 20 pounds) are required. When the nurse case manager is out of the room, the doctor and the patient won’t feel rushed or pressured. They can review each job task that you must do to work.

You have the right to be present when the doctor or health provider and the nurse case manager review your case. The nurse case manager is supposed to be working for you, even though in fact, she is an agent of the insurance company. You have the right to know what is being discussed about your case. If a nurse case manager violates this right, you should inform your lawyer.

You also have the right to challenge any inappropriate activity the nurse case manager engages in.  Despite her name, the nurse case manager MAY NOT manage your medical care. That is the job of your treating physician. For instance, your nurse case manager does not get to decide what kind of treatments you need and where they may take place. An NCM’s attempt to divert you to another facility for additional testing or away from a specific specialist recommended by your doctor is not allowed. Her refrain that such a facility or specialist is “not in our network” holds no weight with the Commission. If your treating doctor recommends a certain facility or specialist, then that is where you are to go and the NCM has no right to interfere.

If such attempts to manage your care become an issue, your lawyer may request that the NCM be removed from your case and another nurse case manager be assigned to your case.

Get help from an experienced North Carolina and Virginia workers’ compensation lawyer today

Attorney Joe Miller has been a strong advocate for North Carolina and Virginia workers for more than 30 years. He’s helped thousands of injured workers get a just recovery. He’ll guide you through every stop of the workers’ compensation process including dealing with a nurse case manager. To make a free appointment, please call 1-(888) 694-1671 or complete my contact form.

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5500-B Greenwich Rd.
Virginia Beach, VA 23462

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507 E Main St #K
Elizabeth City, NC 27907

If you are looking at this site, you or a loved one has probably been hurt. If that's true, you've come to the right place. Helping people who have been hurt is what we do. In fact, it is all we do. Joe Miller Law is a law firm concentrating exclusively on representing people who are injured by the carelessness of others or those hurt on the job. We provide the highest quality legal services to people who have been seriously injured. We practice Personal Injury law and Workmens' Compensation law in both Virginia and North Carolina.