A qualified and experienced legal nurse consultant (LNC) assists a hiring firm’s litigation team or insurance adjusters in numerous critical ways, one of which includes case management. Case management services often include managing the medical aspect of claims resulting from catastrophic events (trauma, CNS injuries); accidental injury claims; automobile and general liability claims; private health care standards claims and many more.

There are multiple reasons why a Nurse Case Manager (NCM) is helpful on a case.  I have listed 5 reasons below. However, it should also be remembered that NCMs can be used in a variety of ways including- the group health setting, with catastrophic illnesses, elder care and in the public sector.

Five Reasons to Use NCM Services on a Workers’ Comp Case

Always bear in mind that NCM are governed by individual state laws, regulations and the standards of practice as put forth by the Case Management Society of America.

  1. Hire an NCM to elicit information from the doctor that you, as the adjustor, cannot.  Due to her medical background, the NCM can obtain more accurate and detailed information from the physician regarding treatment strategy and protocols. Hire the NCM to observe a predetermined number of doctor visits with the patient. She can talk to the physician on a peer-to-peer level; thus, gaining valuable information about his treatment plan and timeline. For example, a scenario where an Independent Medical Examiner (IME) advocates ongoing disability or off-work status for a patient with a sprain- or strain-related injury who has been down over six weeks, and relates it back to the workers’ compensation injury begs for the services of an NCM.  In addition to obtaining medical information, the mechanism of injury of the event/causation of the conditions need to be established /commented on by the physician as soon as possible. The NCM should find out the exact diagnosis and treatment plan, nature of the backup plan, whether the physician is considering referring the patient to an orthopedist for evaluation. The treating physician will see that you are actively working the file and that you will not allow ongoing failed conservative treatment strategies. In addition, early intervention and referral helps to obtain information regarding casualty issues.
  2. Hire an NCM if you’ve been assigned a claim in an unfamiliar state or region with physicians you do not know. An experienced NCM from the state or region will know the area and the doctors. Frequently, she has resources allowing quick access background information about the treating physician. Pertinent background information will include reference to the doctor’s past success with compensation claims and common treatment plans ordered. For example, although they should, some surgeons do not attempt conservative treatment plans before recommending surgery. The NCM can provide valuable information about the physician’s modus operandi in advance of the initial office visit, avoiding unwelcome surprises.  Working with physicians and other providers face to face always results in a more positive outcome.
  3. Hire an NCM at the beginning of a complex claim to calm an anxious, frightened claimant and to obtain necessary documents/information rapidly. The nursing world is a small one and a good NCM will know someone somewhere who will expedite the release of necessary medical records, which is vital in cases with seriously injured claimants. It is imperative that the NCM follow all HIPPA rules/guidelines/consents when obtaining medical information.  A face to face interview with the patient-claimant is an excellent way to establish trust, communication. Get the NCM to talk to the patient and answer any questions prior to talking to the claimant yourself. Talking to a professional nurse puts the claimant psychologically at ease, relieving anxiety and mental burdens. He feels supported and cared for, which is the first step toward healing.
  4.  Hire an NCM if the claimant has one medical issue associated with the case and another non work-related medical issue. For example, the worker may have broken his olecranon process (elbow) in a workplace fall, but while in the emergency room, physicians discover bursitis, elbow spurs, and nerve degeneration. Although the workers’ comp claim only covers the injury obtained in the workplace, the broken elbow, doctors must take care of the non work-related issues at the same time. The NCM and your staff counsel can help clarify the distinction between surgical repairs associated with the work-related injury and the other issues. This clarification should help differentiate what to cover and what not to cover under the workers’ compensation insurance claim.
  5.  Hire an NCM to collaborate with you when the MD recommendations indicate the claimant should return to full duty soon, but the claimant has not yet returned to the physical status necessary to do so, or return to work (RTW) has been delayed for whatever reason. The NCM can consult with the treating physician and review the patient’s records and help determine why he has not achieved adequate healing and/or has other delays in his RTW status. Delays in healing can indicate a red flag for the claim; the NCM can determine if other medical issues exist or if the patient has reluctance or fear about returning to work.

 

The Independent LNC/NCM – An Adjustor’s Friend

When choosing an NCM, take care to check that she holds current, acceptable credentials and that she is ACTIVELY licensed as a RN (Registered Nurse). While a nurse does not have to have a certification to practice as a NCM, certification does indicate that a nurse has met certain credentialing criteria, maintains continuing education and has sought to broaden her knowledge base for that particular certification.

Depending on the type of case management a NCM is practicing will also influence her choice of certification.  Additionally there are some states that require specific/additional credentialing/requirements to practice in that state.

A few of the certifications associated with Case Management are: CCM (Certified Case Manager or Case Manager, Certified), CDMS (Certified Disability Management Specialist), CRRN (Certified Rehabilitation Registered Nurse), CMAC (Case Management Administrator, Certified), LNCC (Legal Nurse Consultant-Certified) and RN-NCM (Registered Nurse- Nurse Case Manager).

An experienced, professional LNC/NCM is a valuable asset in the proper handling of certain claims. When you find a great one, share the wealth with others in the industry that could use her services.

 

Additional Resources

Case Management Accreditation and Certification Program

American Legal Nurse Consultant Certification Board

Commission for Case Manager Certification

Case Management Society of America