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Title: Medical Case Managers?

Question:

Earlier this year, I injured my back while lifting a box at work. The company authorized physician has told me that I have a permanent injury which will require surgery. At my last appointment with the doctor, an individual showed up whom I had never met before. She introduced herself as a "medical case manager" who had been hired by my employer's workers' compensation carrier to manage my care. She sat through my appointment with the doctor, and when my appointment was over, she and the doctor talked about my treatment. After she talked with the doctor, she told me that I no longer needed surgery. She also told me that my care was being transferred to another doctor who specializes in more conservative methods of treatment. Who is this person? Does she have the right to sit in on my appointments and control my medical care?

Answer:

In simple terms, a medical case manager is an individual who has been hired by the workers' compensation insurance carrier to give the carrier more control over your medical care. Some of the larger insurance companies have actually hired nurses to become part of their staff and perform case management services full time, while others use independent case management agencies.

Under the law in Iowa, if the workers' compensation carrier has accepted responsibility for your injury, then the carrier has the right to control your medical care. This gives the carrier the right to hire case managers, and it gives the case manager some authority to direct your care. However, there are limitations on what the case manager is allowed to do.

To begin with, the case manager does not have an automatic right to sit through your appointments. If you are uncomfortable with her presence in the examining room, then ask her to remain outside. In addition, you have the right to know why your care is being transferred to another doctor. Press her for an explanation, and discuss this explanation with your current doctor to make sure that you are comfortable with it. Although the insurance carrier does have the right to control your care, the carrier has an obligation to make sure that the care you receive is reasonably suited to treat your injuries. You have the right to know that there are legitimate medical reasons-rather than simply financial reasons-for your change in care.

You also have the right to review any records which the case manager provides to the carrier, or anyone else, regarding your physical condition. If you ask her for copies of her reports or other written documents concerning your condition, she must provide these to you.

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