Medical Case Managers

Author: Michael T. Brown, Jr. Workers Compensation Practice Group Leader / Chief Operations Officer

If you have a workers’ compensation claim that is accepted, the insurance company may hire a Medical Case Manager (MCM; also known as “nurse case manager”) to work with you on your claim. There is no guarantee that you will be assigned a MCM. The insurance company normally makes this decision.

However, if you are assigned a MCM, your MCM’s general role is to schedule medical appointments as quickly as possible, facilitate further medical care recommended by your doctor, and relay all information back to the employer and insurance company. Many times, your MCM will attend your doctor’s appointments in person. This is not a requirement though. Many MCM are telephonic only meaning that they will only contact you and your doctor by phone.

If your MCM does attend your appointments, you have a right to have a private medical exam with your doctor without the MCM present. Once the exam ends, the MCM can come back and meet with you and your doctor to get an update. Remember, the MCM is there to assist you and facilitate medical care. They are not there to tell the doctor what to do nor should they.

Once your doctor makes their recommendations for treatment, your MCM should relay that information to the insurance company and request that the recommended treatment be approved. Once approved, the MCM should schedule the recommended treatment.

The role of the NCM is bound by a set of rules issued by the Industrial Commission. These rules can be found here.

  • MCM’s can be a big help for you during your claim. They can facilitate medical care and get you in for treatment quicker than if you are having to deal with scheduling by yourself. However, keep the following points in mind:
  • Assume everything you say to the MCM or in their presence will be reported to the carrier or show up in a report. They are required to report all information to the carrier so assume they will do exactly that.
  • Keep notes of what the doctor actually recommends to you and says to you during an appointment. MCM’s are human and they make mistakes even if they are trying to help you. You do not want information showing up in their report that incorrectly reflects what your doctor has said.
  • With any profession, there are great MCM’s, good MCM’s, mediocre MCM’s, and some that just aren’t that great. If you think the MCM assigned to your case isn’t doing their job, or is trying to do something inappropriate, please report that to your attorney.
  • The MCM should not be meeting with or talking to your doctor without you present. If you see this occur or if you believe it is occurring, politely speak up and address it with your MCM or talk with your attorney.
  • Remember, you have the right to a private exam. If your MCM doesn’t agree that is your right, ask them to show you in the rules where you have to let them attend the exam. Also, speak with your attorney if this arises.
  • Never sign anything presented to you by your MCM without first talking with your attorney.
  • You, and / or your attorney, should receive copies of all correspondence sent by your MCM to anyone regarding your case. This includes reports, emails, and faxes.
  • While your MCM might be great, they can not fix all issues in your workers’ compensation claim. If the issue involves medical care, your MCM will likely be able to talk with you about the problem and explain the situation. If the issue involves out of work time, impairment, return to work, or something outside medical care, then your MCM will likely not be able to talk with you. Your best bet in those situations is to call your adjuster or call an attorney.

Remember, MCM’s can do a lot to speed up your medical care and assist in getting you appointments, relaying information, and moving your care along. However, stay on guard and be mindful that there are certain things they are not allowed to do. If you have questions, call an attorney. We at Crumley Roberts will be happy to discuss your situation.

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