Nurse Case Managers

Massachusetts Workers’ Compensation Attorneys

The Massachusetts disability lawyers at Kantrovitz & Associates are dedicated to defending the rights of injured workers who need medical care. Serious work-related injuries require extensive treatment reviewed by nurse case managers and insurance claims adjusters. For over 20 years, the attorneys in our Boston office have favorably resolved such medical disputes for injured workers throughout Massachusetts, Rhode Island, and New Hampshire.

Role of Nurse Case Managers

Massachusetts General Law (MGL) c. 152 requires that employers and insurers pay for medical treatment and lost wages resulting from a job-related injury. Regardless of fault, employees are entitled to coverage for “necessary and reasonable” medical treatment. But before receiving medical service, injury claims must pass the “utilization review” (UR) process required to determine medical necessity. Separate vendors, contracted by the workers’ compensation insurers, conduct UR pursuant to criteria established by the Massachusetts Department of Industrial Accidents. They review requested tests and treatments for compliance with these rules and “objective clinical findings.”

Communication with Claimants

NCMs are also chiefly responsible for communicating with patients about resolving medical injury claims. If UR determines that a requested treatment is not “medically necessary,” NCMs may assist practitioners in resolving disputes between UR and the injured worker’s physician. At all times, injured workers must be notified of the determination. This often requires:

• Reviewing claim and medical records following an accident or injury
• Contacting worker to explain or answer questions about covered medical benefits
• Notifying employees of clearance for return to “transitional, modified” work
• Maintaining communication with injured workers eligible for timely medical care
• Alerting claims adjusters to cases requiring NCM services or independent medical exams
• Explaining length of treatment limits and process to review or appeal denied claims

The UR management process continues until medical issues are resolved. NCMs can assist practitioners in reviewing denied claims, evaluating the merit of continued payment of benefits, and identifying potential cases of fraud. They may also help employers and insurers prepare UR files for resolution through dispute resolution or independent medical examination.

Discretion of Claims Adjusters

Although UR agents review requested treatment against established criteria for medical necessity, claims adjusters do have discretion to approve additional treatment that exceeds the guidelines. In about 10% of cases, claims adjusters may determine that the patient warrants a procedure not otherwise allowed under the guidelines. NCMs typically assist in making these determinations. This decision depends on various factors, including:

• Specific objective clinical findings
• Requested treatment being “appropriate”
• Initial UR agent using wrong guidelines
• Whether UR is prospective or concurrent
• Change of diagnosis by medical practitioner
• Support for continued care despite improvement

NCMs only have limited access to UR information and medical documents. Only claims adjusters have direct access. NCMs are also prohibited from determining the medical necessity of a partially approved claim. NCMs cannot issue a denial, but must notify workers of the appeals process for the treatment that was denied.

Recovering Benefits

If you have any questions about information conveyed by a nurse case manager, the Massachusetts workers’ compensation attorneys of Kantrovitz & Associates can help. With over 20 years of experience handling work injury claims, we are skilled at obtaining necessary medical treatment and workers’ compensation benefits after an injury. We have successfully appealed denied medical care for injured workers in Boston, Middlesex, Norfolk, Essex, Suffolk, Plymouth, Merrimack River, and other counties. Call 800-367-0871 for a free consultation or contact us online.