Comp Clues


Does Case Management have a role in Surveillance?

By Samantha Garrison, RN, BSN, CCM, GENEX Services, Inc.
| Date: 04/01/2010

The short unequivocal answer is NO.

Surveillance is a Legal/Claims action that directly impacts the compensability of the file. While Case Managers face medico legal and ethical issues they do not have a role in claims.

Case Management has many benefits to your case but most importantly as the claimant’s advocate. That person who is neutral at all times. The person you can rely on for unbiased communication with all parties for the sole purpose and goal of assisting the claimant to return to the pre-injury state of the injured worker. The Case Manager is always assessing, planning, implementing, evaluating and communicating all pertinent information to the worker’s compensation team. By doing this, the Case Manager ensures the case progresses toward resolution of the medical injury in the most effective and timely manner.

The CMSA Standards of Practice dictate the Case Manager’s central focus is on the claimant. Ideally, the Case Manager should advocate both for the claimant and for the payer to facilitate positive outcomes. However, when a conflict arises, the needs of the claimant must be the priority.  The Case Manager will advocate for the claimant at the service-delivery level.  The Case Manager has to establish an effective and respectful relationship with the claimant, payer, physician, other health care providers and other relevant parties.

Case Managers are able to and should provide information to the adjuster as requested regarding the case. This can include the known schedule of appointments and work as well as a physical description of the claimant. This falls in the realm of communication. The Case Manager provides identification of issues affecting the claimant’s progress through the medical process toward recovery. This will include inconsistencies in behavior and barriers to recovery.

Case Managers can, under no circumstances, take part in claims activities. This includes surveillance. It also includes knowledge of, handling, viewing, offering opinions on surveillance. To do this puts the Case Manager in the adjuster/claims role and is outside the Case Manager’s scope of practice.

Does that mean that the Case Manager is not “key” in identifying inconsistencies? NO. Working as the advocate of the claimant, the Case Manager does and should identify inconsistencies in behavior. Is the claimant limping after the appointment but not on the way back to the exam room? A claimant with a back strain who brags about the engine he is working on in his spare time. Does the claimant have dirty fingernails, post-surgery, for a hand injury? These are issues of compliance and affect the progress of the medical care and are directly related to our role to assist the claimant progress through the medical maze toward the goal of successful return to the pre-injury state that includes RTW.

In order to be effective in the case, the Case Manager has to maintain the claimant advocate role. If surveillance is necessary in the course of the claim, that surveillance MUST be initiated, carried out and communicated to the physician outside the presence/knowledge of the Case Manager.

Samantha Garrison, RN, BSN, CCM
GENEX Services, Inc.
Assistant Branch Manager/Case Management Supervisor