Workers Comp Zone


One aspect of doing the blog is that people send me letters and e mails.

Today I received this unsolicited but noteworthy inquiry from an injured worker (not a client of our firm), which I’ll quote in its entirety:

“I wanted to send you an e-mail about an issue that may or may not be a standard of practice. I had a nurse case manager (without my knowledge at the time) who also acted as my utilization review nurse. I found this out after I subpoenaed my records from (redacted) UR company. In my records were copies of correspondence from my claims adjuster to a nurse case manager from the same company who does my utilization reviews (redacted company name). I called (redacted company name) for telephonic responses to UR determinations, and talked to a nurse. This nurse told me she would send the UR response to another doctor. I wrote down the name of this nurse. When I later subpoenaed my records from the UR company, (redacted company name), I found the nurse I talked to was also my case manager.
How can it be legal that the same nurse who is involved with my UR issues can also be hired as my nurse case manager from my self-insured employer? Isn’t this a conflict or is this legal? The nurse case manager had written discussions with my claims adjuster about meeting my primary treating physician and closing my claim. How can she also be involved with my Utilization Review decisions?”

I can’t vouch for the accuracy of the allegations, but I have no reason to doubt them either.

So if true it appears that the firm, a leading provider of both UR services and nurse case manager services which goes my a moniker that plays upon generational changes, was engaging in dual purpose

Like the privacy practices of interpreter companies recently detailed in my post “The Tattlers”, dual purpose nursing may not be illegal.

But dual purpose nursing seems so obviously unethical that regulators and legislators may have assumed that it was not a problem.

A nurse case manager should not be allowed to have a role in utilization reviews for the case of the worker they have managed or monitored, period.

And nurses who have been involved in utilization reviews of a worker’s treatment should not be allowed to serve as the worker’s nurse case manager unless the worker is advised of the fact and consents.

There should be a firewall between nurse case management and utilization review.

Labor Code 4610(e) requires that “No person other than a licensed physician who is competent to evaluate the specific clinical issues involved in the medical treatment services, and where these services are within the scope of the physician’s practice, requested by the physician may modify, delay, or deny requests for authorization of medical treatment for reasons of medical necessity to cure and relieve.” (see also CCR 9792.9)

Many utilization review companies are using nurses as part of the UR process. I often see UR denials that are signed by both a nurse reviewer and an M.D. Occasionally there will be a UR signed only by the nurse, which seems a clear violation of the Labor Code and the California Code of Regs.

And so it may be that some of these nurses involved in the UR process are functioning in dual roles.

Workers and attorneys will want to pay more attention to the role of the nurse case manager and any dual functions. Some of the companies providing these services may be running amok and need to be subject to scrutiny.

If examples can be confirmed, a regulatory fix is in order.

Stay tuned.

Julius Young

Category: Medical treatment under WC