A Challenging Day as a Work Comp Case Manager

Here is what a bad day in case management might look like. You are the CM and doing a stellar job supporting your injured worker and keeping everyone up to date with the treatment plan. You are sending regular communications to the team, including the claims adjuster and the employer representative – at least weekly but most times 2 to 3 times a week.

The injured worker is a federal employee, injured in the Middle East and you don’t have any current medical records. Your services were requested to assist in finding an occupational medicine provider for an injury that occurred outside of the country. The information you have is minimal. He was involved in a MVA, fractured several ribs and suffered whiplash. You are provided with an MRI report of the cervical spine identifying a C3-C4 herniation as well as spinal stenosis. You are asked to provide a list of 3 local providers to accept federal workers’ compensation to present to the employer. Essentially, you are creating a panel for the employer to present to the injured worker for their choice. In real time, real life, these providers need medical records to review in order to determine if they will accept the case. The offices often take several days to weeks to make this determination – this is in Florida. Work comp is challenging in Florida compared to other states for many reasons. A delay in decision for acceptance is not unusual. Further, the provider offices frequently have their own fee for service requirements, which many out of state employers and claim adjusters are surprised to learn.

Upon acceptance of the referral, you share all of this information with the employer and the claims adjuster.  It may take some time to secure the panel of providers.  There may be a fee associated with not only medical record review but also a pre-appointment compensation fee. The claims adjuster is satisfied, however, the employer representative – who is VERY involved – is not at all satisfied. She wants everything to happen at a much quicker pace. As the case manager, you are patient and continue to communicate via daily updates to the employer representative and you copy your referral source as directed. You continue to do your best to secure a provider for the injured worker.

The employer representative remains dissatisfied. She is even incredulous, stating that this process is very different from her home state! She places blame on you for doing a poor job. She reports you to the referral source as not communicating enough - at not getting the job done. And here’s the kicker – the referral source has used your services for years. They have always been satisfied with your work product. You have received direct requests through this referral source, for your work. Now, however, this employer representative, who is a new client for your referral service, is trying to throw you under the bus.

Does your referral source stand by your work product, and your shared years of providing professional services? Do they “have your back?”

Does the adjuster help the employer representative understand the challenges of securing an appointment?

In our story, sadly, the answer to both questions is “no”.

As the independent case manager, what do you do? Your role as CM is to provide education and support to the injured worker. You have been committed to communicating with the injured worker and providing ongoing updates towards the goal of finding a provider. You have promoted the obligation to do good, and to bolster the injured workers’ legitimate interests. The CM must fall back on their knowledge and intent to practice under ethical guidelines. Personalities exist in the world. And as my mom used to say, “You can’t please everyone all the time.” The CM might consider a conference meeting with all parties so that concerns can be addressed. If the situation cannot be resolved, it may be time to consider re-assignment of a file.