NURSE CASE MANAGEMENT WITH REGARD TO MEDICAL AND HOME CARE

With the erosion of the provision of medical care for injured workers in Workers’ Compensation(the subject of a previous article by that name), there has arisen an entire caldron of issues of Workers’ Compensation Lawyers in California.

Aside from the requirement that medical care be rendered through an MPN (Medical Care Provider) and that it is subject to UR review (and “appeal” through IMR -“Independent Medical Review,” insurance companies and carriers although “admitting” injury, are now denying “body parts” injured under California Workers’ Compensation Laws and they interpret it.

For example, although an injured worker in California may have an “admitted” lumbar spine injury, the insurance company will commonly deny an injured thoracic or cervical spine.  This likely means that the injured worker will not be able to treat a related area although claiming injury to that part of the body.  The remedy is usually to either provide treatment to an injured worker on a “lien” basis or to request an AME (Agreed Medical Examiner), and if not agreed, to utilize a PQME (Panel Qualified Medical Examiner) in the field of concern (orthopedics in this example) so as to render an opinion as to the work-relatedness of injury to that part of the body.

We have also been successful in have a nurse-case manager manage not only the industrial but the non-industrial medical treatment in instances where there may not be that clear of a distinction.  For example, in one case handled by Roland Pennington an Trodden, a “Finding” of 100% industrial disability was made in the late 1980s due to Lupus.  This individual contracted a theretofore dormant Lupus condition as a result of being mandated to take a live flu vaccine, which “lit up” her Lupus condition.  As a result, she now has problems with Sjogren’s (a condition which does not allow the body to have sufficient fluids) as well as many other conditions, including dental (lack of saliva), sex (lack of fluids).  The Employer/carrier denied treatment for that condition, which seemed to be less than candid.  What we were able to do, is to have the same Nurse Case Manager manage the “non-industrial” so as to allow for private coverage or Medicare.

It is indeed a daunting task to obtain appropriate medical care, let alone good.  We, at Roland, Pennington Trodden have been working toward this end with a combined experience of over 100 years in Workers’ Compensation in the Los Angeles and surrounding areas.

 

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