South Carolina Workers’ Compensation Nurse Case Managers – Devils or Angels?

Doctor and workers comp case manager reviewing xrays

By: Attorney Ken Harrell

Kenny Harrell is the managing partner of the Joye Law Firm. The Joye Law Firm has focused on handling South Carolina personal injury and workers’ compensation cases for over 50 years and has offices in Charleston, Columbia, Myrtle Beach and Clinton. Harrell has been recognized several times by Super Lawyers and by Best Lawyers as one of South Carolina’s top lawyers, both in the areas of workers’ compensation claimants’ and personal injury plaintiffs’ cases. Harrell formerly served as the president of the South Carolina Injured Workers’ Advocates organization and he has served as the co-chairman of this group’s legislative affairs committee for nearly 15 years.

If you have suffered a significant work injury in South Carolina, there’s a good chance that you have dealt with a nurse case manager hired by the workers’ compensation insurance company.  If so, you may be asking – what is this person’s job and are they good or bad for me?

What does a Nurse Case Manager Do?

First, the boilerplate role of the nurse case manager is to coordinate medical care for an injured worker while serving as a conduit of information between the treating doctors and the workers’ compensation insurance company.  Typically, the assigned nurse case manager will attend virtually all of an injured worker’s appointments with medical specialists.  OK, now that’s the vanilla description of a nurse case manager but what are they trying to accomplish and are they good or bad for the injured worker?

As to the primary role of a South Carolina nurse case manager, anyone who argues that they are not touting their services to insurance companies by claiming that they can help hold down medical costs is naïve and is also ignoring their marketing messages.  Corvel is likely the largest employer of nurse case managers in South Carolina (and perhaps in the country).  Corvel’s website defines its nurse case management as, “In actuality, case management is synonymous with savings – including decreasing inappropriate care and reducing hospital readmissions – when utilized effectively.”  Now there is nothing wrong with saving money but if this is a primary goal of the nurse case manager, would there involvement be a negative thing for the injured worker?

Do Nurse Case Managers Help or Hurt Injured Workers?

Actually, whether a nurse case manager’s involvement is good or bad for an injured worker depends on a number of factors.

First and foremost, the identity of the nurse case manager.  I have now been practicing law for well over 30 years.  During the first half of my legal career, I rarely encountered a nurse case manager but over the past 15 years, it is rare to have a case involving a significant work injury in South Carolina where a nurse case manager is not used.  Over the past 15 years, I have met some nurse case managers who clearly maintained an emphasis on their role as a “nurse” and who have advocated with me to get my clients the treatment they need.  These are the “angels” in the profession.  I’d like to think that the best nurse case managers have been equally impressed with the Joye Law Firm as several of them have hired our firm to represent them after they were injured on the job or in a car accident.  On the other hand, I have also encountered some nurse case managers who eventually proved that they could not be trusted in a host of ways.  This included inappropriate ex parte contact with my clients’ treating doctors and, in a few cases, actively encouraging clients to fire us based on the fallacy that “you won’t be any better off with a lawyer representing you.”  These are the “devils” in the profession.  It’s not a lengthy list but my firm has a blacklist of nurse case managers who are NEVER allowed to work with one of our clients.  Between the two extremes described above are the majority of nurse case managers.  These nurses typically adhere to the rules when it comes to appropriate contact with the doctors, can certainly be helpful in coordinating treatment, but also never lose sight of the fact that they are hired by and paid by the insurance company (so cutting costs on the treatment is always part of their focus).

A second factor affecting how helpful a nurse case manager can be is the severity (and complexity) of the worker’s injuries.  If you have a relatively straight-forward injury (such as a torn meniscus in one knee), I’m not convinced that a nurse case manager is much needed, although the insurance company is still likely to hire one.  (Insurance companies are massive, bureaucratic enterprises.  Once a practice, such as hiring nurse case managers, becomes the norm, it’s all but impossible to convince an adjuster to do some creative thinking and paint outside of the numbered boxes.)  For the most serious injuries (such as paralysis or a traumatic brain injury) or in cases involving a number of different types of injuries (and therefore, a number of different types of providers), a good nurse case manager can be invaluable.  It’s hard for doctors to coordinate their treatment efforts with other doctors and the nurse case manager is often the person in the best position to tell the left hand what the right hand is doing.

Inappropriate Conduct by Workers’ Comp Nurse Case Managers

The number one complaint we hear from our clients about nurse case managers is that many of them push the treating doctor to release an injured worker from medical treatment as soon as possible.  Many clients also complain that they feel the nurse case manager is meeting with their doctor outside of their presence in order to try to influence the doctor’s treatment plan, something which is not supposed to be done.

Given the number of complaints about inappropriate contacts with doctors by nurse case managers, our legislature added a statutory provision about this issue when the South Carolina Workers’ Compensation Act last underwent a significant revision in 2007.  In section 42-15-95, a nurse case manager (as well as adjusters and insurance defense lawyers) are not to have direct contact with the treating doctor to discuss the injured worker’s status unless the injured worker is given timely advance notice of the proposed meeting and given an opportunity to attend.  If written questions are sent to a treating doctor, the questions must be sent to the injured worker at the same time.  This provision also goes on to state that the discussion or communication with the treating doctor is not to interfere with the employee’s examination or treatment.  If these protocols are not followed, any medical reports or opinions obtained are to be excluded from any workers’ compensation proceeding.

How to Interact with a Nurse Case Manager During Your Claim

So how should you interact with the nurse case manager if you are the injured worker?  First, always insist that the nurse case manager not be present during your actual examination by the doctor.  If the doctor is willing to meet with the nurse case manager after your examination is done, stick around to be present for the conversation between your doctor and the nurse case manager.  Second, I would start by giving the nurse case manager the benefit of the doubt.  Perhaps I am a bit of an eternal optimist but it’s always been my impression that most people want to do the right thing and want to follow the rules.  While your nurse case manager cannot authorize recommended treatments for you (only the adjuster can do that), she can help speed up your receipt of recommended treatment by asking the adjuster to schedule it long before the treating doctor’s report is received (that can often take weeks).  If you are represented by a lawyer and you feel that your nurse case manager has acted in a way inconsistent with your best interests, let your lawyer know that.  At the Joye Law Firm, we have removed a number of nurse case managers from our clients’ cases by requesting that the nurse case manager no longer have any direct contact with our client.  That doesn’t happen often but the client is in a better position than we are to determine if something feels off about the way the nurse case manager is handling his case.