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Medical Case Management

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Medical Case Management refers to the planning and coordination of health care services appropriate to achieve the goal of medical rehabilitation.

Medical case management may include, but is not limited to:

  • Care assessment, including a personal interview with the injured employee
  • Assistance in developing, implementing and coordinating a medical care plan for the injured worker with the health care providers, the employee and his/her family
  • Evaluation of treatment results.

Medical case management isn’t medical care. The goal of medical case management is to help the injured individual understand all available treatment options, so they can make an informed choice.

Role of the Medical Case Manager

An injured worker is entitled to medical care and treatment that is reasonable, necessary and related to their work injury.

The employer (or carrier) is required to provide the injured worker with these medical benefits; however, the injured worker has a right to choose their physician and health care providers.

The employer/carrier must bear the cost of medical care the worker selects, but the carrier may take action to ensure the efficient delivery and proper utilization of such medical benefits.

The Medical Case Manager (MCM) is hired by the employer/carrier to medically follow, or medically manage, the injured worker.

Qualifications

Most medical case managers are registered nurses, and the Vermont workers’ compensation system requests that MCM’s obtain licensure by the Vermont Board of Nursing. MCM’s are also required to have relevant work experience working with claimants in the Vermont workers’ compensation system. The Department requests that MCM’s without this specific work experience first being their work as interns, working under the direct supervision of an experienced MCM.

Agent of the Insurance Carrier

The MCM is an agent of the insurance carrier. They may work for a medical case management company, but directly or indirectly, the MCM is hired by, and paid for, by the employer/carrier.

The MCM’s role is to assist the injured worker in understanding and obtaining appropriate medical care. However, because the MCM is an agent and/or employee of the employer/carrier, s/he may also ask questions or perform activities that are beneficial to the employer/carrier. The MCM is encouraged to provide the injured worker a disclosure statement notifying the worker of their employment relationship with a medical management vendor or insurance carrier.

Examples Medical case management examples may help provide an understanding of the MCM role and what an injured worker may expect from an MCM.

 1) The worker’s doctor recommends physical therapy. The MCM may assist in locating a physical therapist and scheduling physical therapy appointments.

2) The worker’s doctor may recommend a diagnostic test such as an MRI. The MCM may help locate a medical office that can perform the MRI promptly, near the worker.

3) The worker’s doctor may recommend referral to a specialist. The MCM may help locate and provide information concerning the specialist and the care anticipated.

Medical Case Management is Non-Voluntary

It is up to the insurance carrier to utilize medical case management. The injured worker has no authority, to request or deny the use of a MCM in their case. .

Medical Management – Medical Release Limitations

The injured worker is required to provide a medical authorization to the insurance adjuster, to release their medical information to the MCM. While the injured worker doesn’t have to provide this authorization, because the MCM is considered an agent of the insurer, they can obtain the medical information through the adjuster.

An injured worker may choose to provide additional medical authorization to the MCM, either written or verbally. But the injured worker isn’t obligated to provide this additional authorization for the MCM’s involvement in their case.

Additional authorization could allow the MCM to be present for a medical office visit, and/or to discuss the injured workers case with a medical provider.

However, if the worker doesn’t sign a medical authorization for the MCM, or verbally agree to the MCM speaking with his/her medical care providers, then the MCM’s role will be limited in the case.

Of note, many insurers request that MCM’s attend medical appointments with injured workers to obtain current medical information and to expedite their ongoing medical care. The injured worker may allow or authorize such direct involvement of the MCM with their care providers or not.

Other Medical Management Limitations

Regardless of whether or not the worker authorizes the release of their medical information, the medical case manager has a defined role.

They cannot function as an adjuster or as a medical care provider.

Only a licensed adjuster’s may adjust claims and deny benefits.

The MCM cannot adjust the claim; therefore they cannot deny the worker medical care or treatment.

A MCM also cannot direct the worker’s care. The MCM may provide information concerning different treatment options but they cannot cancel or select the injured worker’s care.

Medical care decisions are up to the injured worker, based upon the expertise and recommendations of the injured worker’s medical care providers.

Disputes in Medical Case Management

Disagreements may arise in a workers’ compensation claim over a medical case management issue.

The workers’ compensation division encourages informal resolution of disputes.

If an injured worker has a complaint or concern about a MCM, it is best for the worker to write a letter, stating the complaint or concern and providing specific information.

The letter should be written to the Department, the MCM and the adjuster.

Phone calls may resolve some issues but an unresolved complaint should be followed up in writing.

For any dispute, it is possible to request intervention from the department, such as an informal conference, to air the dispute and to attempt to resolve it appropriately.