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What is Actief Case Management,
Inc.?
What is the difference
between a claim manager and a case manager?
Why is a nurse consultant/case
manager contacting me?
I have a friend who has
the same injury and he doesn’t have a nurse consultant.
Why is that?
Do I have to work with
a nurse case manager?
Why do you want to attend
my appointment with me?
Why go back when I can’t
do my regular job?
Where can I find out more?
What
is Actief Case Management, Inc.?
Actief Case Management, Inc. is an independent nurse owned consulting
company. We are not a subsidiary of an insurance agency or employees
of your insurance adjustor, your employer or the California
Division of Workers’ Compensation. Actief Case Management,
Inc. nurse consultants are registered nurses with hospital and
clinic nursing backgrounds, many experienced in critical care
areas.
What
is the difference between a claim manager and a case manager?
The claim manager (adjustor) is an insurance specialist. The
claim manager (adjustor) handles the business end of your claim,
pays bills, and confirms authorization for goods and services.
The claim manager is an employee of your insurance carrier.
The case manager (nurse) is a medical specialist. While some
insurance carriers employ in-house case managers with various
medical backgrounds, Actief case managers are Registered Nurses
who are not employees of your insurance carrier. The case manager
(nurse) does not make payments and can only authorize care within
guidelines set by the claims manager. The case manager is a
professional information resource and patient advocate.
Why
is a nurse consultant/case manager contacting me?
We could be contacting you for one of several reasons.
Usually we are asked to clarify status, a treatment plan or
work restrictions. Sometimes we are asked to help locate and
coordinate services or equipment for you. Our function is to
solve problems and act as a medical resource for you and your
claim adjustor.
I
have a friend who has the same injury and he doesn’t have
a nurse consultant. Why is that?
No two cases are ever exactly the same. Your insurance adjustor
might be swamped with files and unable to find the time to coordinate
your care. Your problem might need surgery where your friend’s
does not. Your friend’s doctor might be providing better
records explaining treatment requests than your doctor’s
office does. Your claim manager might prefer to outsource some
of the medical management to a nurse specialist.
Do
I have to work with a nurse case manager?
No, you do not. The only person you are required to work with
is your primary treatment provider, usually a physician, who
you must see at least once every 45 days by state guidelines.
Any other consultant on your case, medical provider, physical
therapist, occupational therapist, nurse or any other consultant
is required to have your consent to work with you.
If you have retained an attorney you have given that person
the right to act as your agent. In that event we would contact
the attorney directly and ask consent to work with you, rather
than calling you personally to ask.
Why
do you want to attend my appointment with me?
A nurse consultant attends appointments to facilitate your care.
As in the hospital, nurses meet with doctors and patients to
discuss treatment plans, address problems, clarify orders and
obtain necessary paperwork for treatment to proceed. The nurse
performs the follow through necessary to enact the treatment
plan.
If you are taken off work we obtain the documents necessary
for your employer and insurance adjustor to be officially notified.
If you are given modified duty work restrictions we make certain
these instructions are given in writing to you and your employer
and that they are clear.
If equipment or services are requested we obtain the paperwork
necessary to begin the precertification request process. Once
authorization is received we locate a supplier and confirm delivery.
If the physician speaks to you in jargon we clarify his meaning
in English while you are there. Occasionally a patient will
prefer, or be advised by someone, to see the treatment provider
alone during an appointment. We respect your wishes and will
meet the provider or their staff afterward, to obtain necessary
information for your care to continue smoothly. We prefer to
meet together because otherwise your physician has to repeat
information, might forget something and you are not there to
offer your opinion. We prefer an open relationship.
My
lawyer/union rep/friend/brother-in-law/cousin says that you
are working for the other side and cannot be trusted. They say
you just want me to go to work, even if I am injured, because
you are working for my boss/my insurance company/the company
doctor. Whose side are you on?
Gosh, we used to work at the hospital, was the hospital “the
other side?” We never poisoned the patients when their
insurance ran out. At least very few of us did.
In the bizarre world of Workers’ Compensation we are
told that there are “sides”. In this world a registered
nurse “acts against” a patient when encouraging
function while an attorney “acts for” a patient
by protecting them from participating in life’s normal
activity.
Here’s the deal. Medical people are SUPPOSED to try to
help you function more. In the hospital we did our best to get
patients off life support machines and onto their feet. We didn’t
think that we were cheating them out of insurance benefits that
would allow longer treatment in bed on machines. Nurses don’t
want you to function better so that “the company side
wins”. That kind of logic would presuppose that “your
side wins” if you stay injured or get worse. Nurses are
required by law and our licensing board to act in the best medical
interest of our patient, even if doing so conflicts with demands
from the patient, the payment source or the physician on the
case.
For example, we are trained to refuse to administer a drug
that we think might harm you, even though it has been ordered
by a doctor. We are trained to get you moving after surgery,
even when you don’t want to, so that you don’t develop
a blood clot or pneumonia. We are trained to act in what we
believe to be your best medical interest. Nurses believe that
when you recover everyone wins; you, your employer, and your
family. Consider this, when you get better we aren’t needed
and have to stop charging for our service. Therefore your recovery
is not actually in our financial interest. We want to help you
get better anyway. Go figure.
Who
is paying you?
Actief Case Management, Inc. pays your nurse. There is no cost
or co-pay from you. Actief Case Management, Inc. is paid by
they same entity who sold your employer the Workers’ Compensation
insurance. This source pays everyone on your claim, doctors,
nurses, therapists, treatment consultants, the adjustor, pharmacy
and medical equipment suppliers. If you end up receiving disability
payments they will also be paying you. If you have an attorney
and are found to have permanent disability, they will be paying
the attorney a portion of any settlement you might be awarded.
Can
my employer make me to return to work when I still have pain?
Only your primary care provider (PTP) physician can determine
if you are able to return to work. Your employer has the option
of accommodating your return.
Most physicians recommend a work release when they think work
will not be unsafe or cause damage. Studies have shown that
returning to work improves function and decreases overall discomfort.
You might be released to modified duty with restrictions, or
to full duty, even though you still have pain.
Employers are encouraged to accommodate employees. Working usually
pays much better than disability and you will have a better
idea if you can physically perform your previous job. You might
become aware of other jobs available within your company that
are better suited to your needs. You can plan your future more
accurately by participating now.
Family members usually appreciate your return to work because
they can use the couch and remote again. As more than one injured
worker has told us, when asked if he thought he was ready to
return to work; “I’m not sure, but my wife says
that I definitely am”.
Why
go back when I can’t do my regular job?
Injured workers sometimes tell us that they feel punished, being
asked to work modified duty, instead of resting at home until
they are at full capacity. From a medical perspective returning
to a modified job allows you to recondition back up to full
duty. From a financial perspective it pays better than disability.
From a social perspective your employer can see your handsome
face as belonging to their team. From a legal perspective the
State of California, Division of Workers Compensation would
prefer that you go to work and pay taxes rather than sit home
collecting non-taxable income. The state provides financial
incentives for your employer to accommodate an injured worker.
If your employer offers you modified work it isn’t because
they are punishing you. They might consider you a valued member
of the team that they have invested in. Also, their insurance
rates go way up if they don’t let you come back.
Where
can I find out more?
For additional information check out our Resources
page "For Injured Workers" section. The California
Division of Workers’ Compensation website provides information
specific to injured workers. They also provide information and
assistance officers to answer questions and monthly injured
workers workshops.
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