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Independent Medical Review and Nurse Case Managers Post SB 863
By Sue Bowers, RN-BC, BSN, CCM
President, Choices Case Management, Inc.

As a catalyst and independent variable in Utilization Review and the new IMR process, the right NCM can significantly impact any adverse delays in the current system. The NCM offers a bridge in communications so that all parties have immediate access to appropriate care and carrying out of medical treatment requests. The nurse has a unique advantage and understanding of the need to obtain supporting medical documentation to substantiate scientific and evidence based medicine, all within treatment guidelines.

As a Nurse Case Manager (NCM) for the past 19 years, I am used to change and reform in the workers’ compensation system. As with the 2004 reforms, we won't know the impact and efficacy of the 2013 legislative changes until they have been implemented. We have opportunities now to impact immediate treatment and costs, delays in treatment, and disability timeframes. NCMs are a resource and tool available to carriers, employers, and attorneys in the area of Utilization Review (UR) and Independent Medical Reviews (IMR).

The 2004 reforms made utilization review mandatory, but delays in medical treatment added additional costs to claims across the spectrum. Post SB 863, the WCAB will no longer have control over specific current treatment disputes. For injuries occurring on or after January 1, 2013, and for all UR decisions after July 1, 2013, UR decisions can only be appealed through the IMR process. Treatment decisions will be delegated to anonymous IMR doctors to do paper reviews and be the final authority, with very few exceptions.

Labor Code Section 4610.6. states that an “employee or their designee...may assist the employee in seeking independent medical review and advocate on behalf of the employee” This could be a vital and instrumental role for an NCM in the nurse case management and IMR process.

Nurse Case Management is a collaborative process in which the NCM works with the carrier, employer, injured worker, attorneys (if applicable) and the physician. Nurses are one of several tools used on the front-lines as the liaison between the injured worker, employer, carrier, and the physician. Expert and skilled NCMs understand treatment guidelines and standard treatment protocols. NCMs ensure accuracy, appropriateness, and timeliness of medical treatment requests. Often, NCMs are utilized as field case managers to be on-site with the injured worker and the physician. They offer a bridge in communications so that all parties have immediate access to appropriate care and carrying out of medical treatment requests. The NCM will obtain immediate documentation to support any requests for medical treatment and/or other services the physician may request. The nurse has a unique advantage and understanding of the need to obtain supporting medical documentation to substantiate scientific and evidence based medicine, all within treatment guidelines. As a tool in this process, the nurse can benefit all involved by averting any potential delays in both the UR and IMR processes.

Where does the NCM fit in? The right NCM is a highly skilled professional with expertise in workers’ compensation, who understands and knows how to navigate within the system. As a catalyst and independent variable in Utilization Review and the new IMR process, the right NCM can significantly impact any adverse delays in the current system. Since delays are costly and can add to the need for increased care in the future and increased impairment for the worker, the NCM's early intervention makes medical and economic sense.

Sue Bowers, RN-BC, BSN, CCM
Choices Case Management, Inc.
925-679-8828
925-679-8404 (Fax)
Corporate: 925-516-3901 ext-108

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