Medical case management may mean different things to different folks. This article will define medical case management and explain the role of the medical case manager (MCM) in the Vermont workers’ compensation system.
Definition Workers’ Compensation Rule 2.1295 states, “Medical Case Management refers to the planning and coordination of health care services appropriate to achieve the goal of medical rehabilitation. Medical case management may include, but is not limited to, care assessment, including personal interview with the injured employee, and assistance in developing, implementing and coordinating a medical care plan with health care providers, as well as the employee and his/her family and evaluation of treatment results. Medical case management is not the provision of medical care. The goal of medical case management should be to avail the disabled individual of all available treatment options to ensure that the client can make an informed choice.”
Role of the Medical Case Manager The MCM’s role may be better understood by recognizing how it arose and how medical management fits into the workers’ compensation system. An injured worker is entitled to medical care and treatment that is reasonable, necessary and related to their work injury. The employer (or carrier) is required to provide the worker these medical benefits. However, the injured worker has a right to choose their physician and health care providers. The employer/carrier must bear the cost of medical care the worker selects, but the carrier may take action to ensure the efficient delivery and proper utilization of such medical benefits. The MCM is hired by the employer/carrier to medically follow or medically “manage” the injured worker.
Qualifications Most medical case managers are registered nurses (RN’s). The Vermont workers’ compensation system requests that MCM’s obtain licensure by the Vermont Board of Nursing. MCM’s are also required to have relevant work experience working with claimants in the Vermont workers’ compensation system. The Department requests that MCM’s without this specific work experience commence work as Interns, working under the direct supervision of an experience MCM.
Agent of the Insurance Carrier The MCM is an agent of the insurance carrier. S/he may work for a medical case management company, but directly or indirectly, the MCM is hired by and paid for by the employer/carrier. The MCM’s role is to assist the injured worker in understanding and obtaining appropriate medical care. However, because the MCM is an agent and/or employee of the employer/carrier, s/he may also ask questions or perform activities that are beneficial to the employer/carrier. The MCM is encouraged to provide the injured worker a disclosure statement notifying the worker of their employment relationship with a medical management vendor or insurance carrier.
Examples Medical case management examples may help provide an understanding of the MCM role and what an injured worker may expect from an MCM.
1) The worker’s doctor recommends physical therapy. The MCM may assist in locating a physical therapist and scheduling physical therapy appointments.
2) The worker’s doctor may recommend a diagnostic test such as an MRI. The MCM may help locate a medical office that can perform the MRI promptly, near the worker.
3) The worker’s doctor may recommend referral to a specialist. The MCM may help locate and provide information concerning the specialist and the care anticipated.
Medical Case Management is Non-Voluntary Sometimes an injured worker does not want to the assistance or presence of a MCM in their claim. Alternatively, there are injured workers who never hear from or see a MCM and want the help of an MCM. It is up to the insurance carrier to utilize medical case management. The injured worker cannot choose to have one or not. It is considered non-voluntary. As addressed in the following section, the MCM’s role may be broadened with the worker’s authorization or consent.
Medical Management - Medical Release Limitations The medical case manager’s role may be quite broad, or limited, depending upon how much authority the injured worker allows the MCM. The injured worker is required to provide a medical authorization to the insurance adjuster. Because the MCM is considered an agent of the insurer, the MCM can obtain medical information through the adjuster. Consequently, the worker has no obligation to provide an additional medical authorization to the MCM.
The injured worker may agree to provide an additional authorization, or may agree in the medical office setting, to allow the MCM to be present for a medical office visit and/or discussion with a medical provider. However, if the worker does not sign a medical authorization for the MCM, or verbally agree to the MCM speaking with his/her medical care providers, then the MCM’s role is limited in this regard. Of note, many insurers request that MCM’s attend medical appointments with injured workers to obtain current medical information and to expedite their ongoing medical care. The injured worker may allow or authorize such direct involvement of the MCM with their care providers or not.
Other Medical Management Limitations Regardless of whether or not the worker authorizes the release of their medical information, the medical case manager has a defined role. S/he cannot function as an adjuster or as a medical care provider. Only a licensed adjuster’s may adjust claims and deny benefits. The MCM cannot adjust the claim, therefore s/he cannot deny the worker medical care or treatment. A MCM also cannot direct the worker’s care. The MCM may provide information concerning different treatment options but s/he cannot cancel or select the injured worker’s care. Medical care decisions are up to the injured worker, based upon the expertise and recommendations of the injured worker’s medical care providers.
Disputes in Medical Case Management Disagreements may arise in a workers’ compensation claim over a medical case management issue. The workers’ compensation division encourages informal resolution of disputes. If an injured worker has a complaint or concern about a MCM, it is best for the worker to write a letter, stating the complaint or concern and providing specific information. The letter should be written to the department, the MCM and the adjuster. Phone calls may resolve some issues but an unresolved complaint should be followed up in writing. For any dispute, it is possible to request intervention from the department, such as an informal conference, to air the dispute and to attempt to resolve it appropriately.
In review, Medical Case Managers are skilled medical professionals. Workers’ compensation claims revolve around medical issues, therefore the medical case manager may provide invaluable assistance to both the insurance adjuster and the injured worker.
The medical case manager may have a significant role or a limited role in a given workers’ compensation claim. The insurance carrier does not utilize MCM’s in all claims. The injured worker should be aware of the MCM’s role, generally, and the specific role the MCM plays in the worker’s claim.