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...

Crystal's Small Task Saves Big Bucks!

A very special customer to JMS requested a small task in obtaining an impairment rating from a physician. There seemed to be some communication issues, between the adjuster and the physician. The file initially did not have any case management services to help guide the treatment. and at the end of the process nearing file closure, there was a very high impairment rating assigned by the treating physician. Crystal Gilbert, RN got to work! Performing a file review, she found discrepancies with the past surgical history of the injured worker. The injured worker had failed to give an accurate medical history. We gathered and provided the treating physician with medical records showing a prior WC injury to the same extremity and prior surgery to the same extremity of injury. Crystal was able to get a face to face meeting with the physician - because she's just that awesome - and review the medical records and providing documentation of the prior impairment ratin...

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...

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