IME's and Nurse Case Managers in

Worker's Compensation Cases

Pam: So Barry, it sounds like injured employees should have good access to care. Are there any things that people should be aware of?

Barry: Well there are really two areas in particular where injured workers should be cautious. There are things that seem care-related which really aren't. One of these is having a nurse case manager get involved in your case. The other is being sent to a independent medical exam.

Pam: What is a nurse case manager?

Barry: So, when you get hurt on the job and you're off for an extended period of time or you're receiving the kind of care which tends to be fairly expensive, you have to keep in mind that your claim becomes a significant item of expense for the insurance company. And they're gonna bring in a nurse case manager to kind of monitor your care.

Having a nurse case manager brought in can really be kind of intrusive. A lot of times what they'll do is go to all of your doctor's appointments, all of your physical therapy appointments and so forth, and start discussing your care with your doctor, with your physical therapist, and it can be really kind of intrusive, and they can suggest things to the doctor about whether you should be better, whether the insurance carer's going to authorize certain types of care, whether the insurance carer thinks that certain types of care are appropriate, and it can be a real impediment to your relationship with your doctor or your therapist.

Most law firms, when they're representing someone who has a nurse case manager on board, really put significant restrictions on what the nurse case manager can do and can't do. And beyond that, you have to keep in mind that the nurse case manager is gonna be interacting with you, and it's not just that they're going to be listening to what you have to say, they're gonna be checking you out generally.

So to give you an example, I had a client of mine who was hurt in a construction accident, he had a fairly significant back injury, he had a bunch of lifting restrictions put on him, he had restrictions regarding bending and stooping and that kind of thing, and he had a doctor's appointment on a Monday morning, and the nurse case manager showed up and was talking to him in the waiting room, and later I got copies of the report that the nurse case manager wrote to the insurance company, but she was talking about the fact that he had a sunburn, that he had dirt under his fingernails, and it was the kind of thing that was really intended to suggest to the insurance company that the client may have been doing something that was beyond what his restrictions really were.

So, when a nurse case manager gets assigned to a case for a client of mine, I always refer to the nurse case manager as being somebody who's a spy in your camp. Hiring the nurse case manager isn't something that's free, it's a fairly significant expense in and of itself for the insurance company in terms of the claim cost. And you have to keep in mind that these nurse case managers are gonna be selected at least in part on the basis that they're going to be able to do something to help limit the case costs, which means that they're going to try and limit your access to care and interfere with your relationship with your doctor in that way.

So even though there certainly are cases where the nurse case manager can be helpful, they're somebody who needs to be watched with a very careful eye. In most people who are representing themselves or don't have good legal help and have a nurse case manager assigned to them, really come to grief over things that the nurse case manager does.

Pam: Wow, that's disturbing. So what's the deal with an independent medical exam?

Barry: Well, the independent medical exam deserves the full finger quote treatment for the word independent, because it's the farthest thing from independent. Now, where an independent medical exam tends to come into play is when either significant medical care has been suggested, most often before surgery has been suggested, or you have a injured worker who's not getting back to work as quickly as might have been expected.

Now, there are certain doctors who do lots and lots of these quote unquote "independent" medical exams, and those are the doctors who are gonna be selected by the insurance company. The doctor is an independent in the sense of, the worker and the insurance company pick who's going to do the exam. The insurance company makes that decision all on their own, and they have a fairly significant reservoir of experience, in terms of they know pretty well what a doctor is going to say when they send somebody off for an independent medical exam. And typically, the reports that come back will say the injury that the person is claiming isn't related to the accident, that certain types of care aren't needed, that the injured worker's ready to go back to work without restrictions even though their treating doctor says otherwise.

Of course there are times where things work out okay for the injured worker, but you should understand that when somebody gets sent off for the quote unquote "independent" medical exam, it's a significant expense for the insurance company. I've seen bills from these independent medical examiners that are three or four thousand dollars for reviewing some records and doing the exam and writing a report on it, and the insurance company isn't going to make that kind of investment in the expense of the claim without the expectation that there's going to be some report generated by the examiner which is going to say something that's going to be helpful to the insurance company in terms of limiting its exposure in terms of ongoing disability payments or additional medical expenses.

Just to give you an example of what can happen when an injured worker gets sent for an independent medical exam, I had a client of mine, hurt his back in an accident, he'd had surgery, he'd been off work for a year and a half, two years. He was sent to an independent medical exam after having surgery, and the surgeon who examined him said that the original back surgery was completely unnecessary, he said that the client was clear to go back to work without any restrictions. The problem was he didn't know what my guy did for a living. And the question is always, well how can you say that somebody's good to go back to work when you don't know what they do for a living? And he was apparently untroubled by that, but that's the kind of thing that tends to happen when somebody gets sent for an independent medical exam.

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