Medical Benefits

Nurse case managers are advocates of proper medical care and treatment, and they can be tremendous advocates for your safe return to work. Case managers can act as liaisons in the claim management process, and are tasked with coordinating the activities of the various medical professionals and necessary community resources, all while working with the insurance claims adjuster to achieve maximum functional outcomes as quickly and safely as possible. The ultimate goal is a safe return to work.

However, the Workers' Disability Compensation Act does not specifically address nurse case management services. If you feel that the nurse case manager is not managing the process as outlined above, you should first attempt to discuss your concerns with the case manager directly. If this is not helpful, you can discuss the situation with your insurance adjuster. Ultimately you have the right to request a new case manager, or deny further case management assistance entirely.

The medical providers should send their bills directly to the employer or its insurance carrier. The provider will be paid in accord with the Workers' Compensation Health Care Services fee schedule. If for some reason the worker pays the doctor (or other provider including pharmacy) directly out-of-pocket, he or she is entitled to full reimbursement by the employer or insurance company.

The law provides that medical providers such as doctors and hospitals cannot charge more than the amount specified for reimbursement in a fee schedule, and then bill you as the patient for the difference. This is called “balance billing” and it is not allowed.

During the first 28 days starting when the care begins, the employer/insurance carrier has the right to select the medical care providers. After that, the worker is free to change doctors if he or she so desires. In order to change, however, the worker must notify the employer/insurance carrier of the change and provide the name of the physician selected.

You have a right to follow the advice of your personal physician. However, your employer or insurance carrier also has a right to follow the IME recommendations. The options in this case would be to:

1. Follow your doctor's restrictions. The consequence of this may be a suspension of benefits.
2. Show the IME report to your physician for feedback and an opinion that can be sent to the insurance company.
3. If safely possible, try to report to work utilizing the IME restrictions.

If you desire a copy of the IME report, you may make a written request to the insurance carrier. You should receive a complete and correct copy of the report within 15 days of your request.

In cases like these, there are several reasons why the employer may be faltering on their commitment to pay for your claim, or to initiate a claim with their insurance company. We advise employees to file form WC-104A with the agency to initiate a formal mediation hearing in order to determine whether all parties are fulfilling their responsibilities under the Workers' Disability Compensation Act.

Section 315 of the Workers' Disability Compensation Act entitles the worker to all reasonable and necessary medical care. This includes medical, surgical, and hospital services, dental services, crutches, hearing apparatus, chiropractic treatment and nursing care. The responsibility to provide medical care continues indefinitely so long as the need for the care is related to the work injury.