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NURSE CASE MANAGER (NCM)

Ideally, the Nurse Case Manager facilitates effective and efficient treatment and helps the injured worker get well. Unfortunately the reality frequently is that the NCM intermeddles, pushes the Primary Treating Physician to declare the injured worker at "maximum medical improvement" as fast as possible, so temporary disability payments can cease, and acts as an investigative agent for the insurer. A good NCM can be a huge help in a complex case where different treaters are involved, there are transportation difficulties, etc.

There is a paucity of regulatory or decisional law covering NCMs, with only two WCAB panel decisions with contrary rulings. In Lamin v. City of Los Angeles (2004) 69 CCC 1002, the WCAB concluded "that the preferred procedure for selecting a nurse case manager is as follows: (1) the employer or insurance carrier should initially designate a nurse case manager; (2) if the applicant objects (at any time) to the person designated by the defendant, the parties should confer and jointly select a nurse case manager (i.e., an "agreed" nurse case manager); and (3) if the parties are unable to agree on an appropriate nurse case manager within a reasonable period of time (which time period may vary depending on the particular circumstances of the case), the WCJ should resolve the parties' dispute and appoint a nurse case manager."

Label Item Links Comments
Labor Code The treatment statute, Labor Code §4600, includes "nursing".  LC §4600  
Regulations/Rules No specific regs cover NCMs  
Practice Tips The editor includes this paragraph in her letter of representation: "Nurse Case Manager, etc.: No Nurse Case Manager or any other type of nurse not employed by the Primary Treating Physician or consultants has permission to speak directly to the applicant or be present while the applicant is being examined or otherwise meeting with the physician or the physician’s staff. Should we receive a medical report indicating such nursing services are medically necessary, we shall of course reconsider this. We request service of any letters, notes or telephone conversations recorded electronically or otherwise to or from the insurer or administrator or Nurse Case Manager and the Primary Treating Physician or the Primary Treating Physician’s consultants."

As needed, she advises the Primary Treating Physician: "Please be cautious when speaking to the nurse case manager. I do not allow NCMs in the treatment room with my clients. It has been, unfortunately, the practice of the NCMs to attempt to influence the doctor’s opinions with inaccurate factual and legal information. If one comes to your office and insists on speaking to you or your staff, a polite, “I am busy now but you will have my report by the end of the day” or similar is all that is required.
Please note that the Labor Code does not require you to orally discuss [injured worker]'s medical treatment with insurance company agents (which includes the nurse) and the Physician-Patient Privilege does not allow you to. Such communications are ex parte and violate the Physician-Patient Privilege.
   
Magazine Articles The Nurse Case Manager: Interview with Sue Bowers, RN, BSN, CCM

The Faces Behind Narcotics: A Nurse Case Manager’s Perspective by Sue Bowers, RN-BC, BSN, CCM
Bowers on NCM


Bowers on opiates
 The gold standard
Roundtable Independent Medical Review and Nurse Case Managers post SB 863 by Sue Bowers, R.N. Bowers 4-13  
Miscellaneous      

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