The Nurse Case Manager

The spy for the insurance company

The word “nurse” does not appear in the Illinois Workers’ Compensation Act. Nonetheless, there is no person, other than a patient’s doctor, that can so dramatically affect treatment than the nurse case manger.

The use of the nurse case manager originates from a court case known as Hydraulics v. Industrial Commission. The decision, from the 2nd District Illinois Appellate Court, interpreted an Illinois Supreme Court decision known simply among lawyers as Petrillo. The Petrillo ruling by the Illinois Supreme Court created the maxim of Illinois Law that states that a Court may bar “ex parte” communications with treating physicians based upon the patient-physician privilege. An ex parte communication with a treating physician is a communication made by an insurance company attorney, adjuster or other representative without permission of the patient. The Hydraulics Court implemented an evidentiary ruling which excludes from evidence those medical reports or opinions from treating physicians that are the result of ex parte communications.

That’s where the nurses come in. Because attorneys and adjusters are prevented from speaking directly to a patient’s doctor, nurses were then hired by the insurance company to speak (or influence) the doctor.

In fact, these nurses are permitted to talk, speak on the telephone or even gossip with the doctor about the patient’s case and if the patient doesn’t fully understand the law, then that same nurse, who is hired (bought and paid for) by the insurance company can use this access to influence negatively the doctor’s treatment plan. These nurses will even do this outside the presence of the patient. They will often attempt to influence the doctor to prescribe less expensive procedures and medication. They will also push and prod the doctor into sending the patient back to work before he or she is physically ready to do so. In many cases nurses will attempt to push a patient into permitting the nurse involvement. In fact, in many cases, the nurse will just show up or telephone out of the blue, telling the unrepresented patient that a nurse will now be working on the file and simply start showing up at appointments—talking to medical personnel and doctors.

In 1996 the Federal Government enacted the HIPAA medical privacy laws. These laws do much to help keep a patient’s medical records and treatment private. It also gives patients a strong weapon against the nurse case manager. The HIPAA law says that in order to obtain medical records, a nurse must obtain a medical HIPAA release from the patient.

What is the secret? In short, if you do not want a nurse (and you must remember that a nurse is simply a spy in the room) you do not have to have a nurse work with you on your claim. HIPAA gives you the right to say NO. Of course, the nurse will still try to obtain information from you directly. But just remember, there is nothing in the Workers’ Compensation Act that requires an injured worker to cooperate with a nurse case manager.

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This post is also available in: Spanish

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