Working Both Sides of the Fence

Our Case Management role is so multifaceted. While we are patient advocates to help injured workers obtain the best treatment on the road to healing, we also find ourselves working the other side of the fence - working just as hard to expose those defrauding the workers compensation system.

This week one of our RN case managers discovered in review of records that a patient had "chronic" back pain, when she had denied ANY pre-existing back pain or treatment for her reported work injury. This patient DOES need treatment, but it should be on her health plan, NOT workers compensation. On the other side of the fence, he has a patient that was discovered to have a serious underlying cancer causing what he thought was pain from a work incident. He is working with the carrier to refer the patient to an appropriate provider.

Case Management is such a rewarding field, and for so many reasons. It's a great feeling when you've assisted someone to obtain treatment for a serious condition, but it's also a great feeling when you've purged a fraudulent claimant from wasting valuable time and resources.

Comments

Case Management GPS

W The next time I purchase a new vehicle there are several features I have on my wish list. For as much as we case managers travel, Navigation is high on the priority scale to make life easier. Under the pressure of arriving at a physician appointment on time, it's never a good feeling to take a wrong turn or get lost. There are times our role as a case manager is much like a navigator. Deana Scott, RN had that experience just yesterday while attending a physician visit. After three years of treatment for a work injury, the physician had nothing further to offer, and there appeared to be issues of malingering and symptom magnification. There was a point at which the physician actually had a look in his eye of being lost as far as how to bring the treatment course to an end. Confusion centered around the injured worker's return to work goals. It's at times like this, a Case Manager is able to maintain focus and much like a navigato...

A Brilliant Mind

Visit Our Website Connect with me on LinkedIn It’s kind of an inside joke around our office that I’ve been called “brilliant” by a physician for my interpretation of a lumbar MRI. This story happened several years ago when Stacy Mathis, RN working with me in training, and was my witness! This physician is known for his eccentric personality, and he went all out to make me feel as though my critical thinking skills really were brilliant! I was attending a clinic visit for MMI and PPI assignment of a shoulder and lumbar injury. The shoulder had been complicated by a postoperative infection, and was now healed. The lumbar injury had been diagnosed as a strain, although an MRI had been obtained to rule out a disc herniation. I was expecting a high ra...

Pills, Pills, Pills - What's in a Name?

Yes, I know medical terms sound like another language to lay persons. Sometimes we medical people get a good laugh out of patient's pronunciations. My mother always called the "pharmist" to refill her meds. My friend's mother said she needed "cadillac" (cataract) surgery. One injured worker told me he was x-rated and sent home from the ER. But the funniest was a lady talking about her "rotisserie cup" surgery - translated "rotator cuff". Medication names - particularly generic names, can be very confusing. That's why I always recommend carrying a written list of medications in your wallet. It's great to have in an emergency, or when you are filling out clinic history forms. While we can laugh off some mispronunciations, medication names are very important NOT to get confused. Stacy Mathis, RN had a patient this week that is a perfect example. An injured worker had been recommended to return to his psychologi...

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