I recently posted an article about L&I’s Medical Aid Rules and Fee Schedules, which were recently published for 2023. In particular, the L&I Medical Aid Rules can be a great resource for helping work injury claimants understand treatment options. Furthermore, the L&I Fee Schedules can also have a significant impact on work injury claimants and stakeholders.
L&I cuts funding for Nurse Case Managers
As a workers’ compensation attorney who regularly publishes on issues relating to workers’ compensation issues in Washington State, I feel I would be remiss if I did not publicly address and unambiguously condemn L&I’s new fee structure for Nurse Case Managers. I am well aware that L&I has a duty to responsibly manage the Accident Fund. However, cutting fees for Nurse Case Managers is not the way to do it.
Last year, Nurse Case Managers were entitled to bill $116.60/hour for their work in L&I claims. This is a very reasonable rate given their level of education and experience requirements. This year, the 2023 L&I Fee Scheduled caps their fees at a flat rate of $200 per month. While I don’t personally have statistics on this, I strongly suspect the $200 flat fee comes nowhere close to adequately compensating Nurse Case Managers for the work they do. I anticipate that these funding cuts will result in experienced Nurse Case Managers declining to provide services in L&I claims. In fact, I’m already starting to see it happen.
What are Nurse Case Managers?
Nurse Case Managers (NCMs) are registered nurses with one of the following case management certifications: Certification of Disability Management Specialists (CDMS), Commission for Case Manager Certification (CCMC or CMC), Certified Rehabilitation Registered Nurse (CRRN), Certified Occupational Health Nurse (COHN), and/or Certified Occupational Health Nurse-Specialist (COHN-S). In other words, NCMs are highly educated and skilled healthcare professionals. An NCM can be assigned to assist in an L&I claim in many situations. For example, when there has been a catastrophic work-related injury not otherwise being managed under the “Catastrophic Project”. Another example is an L&I claim where the work injury claimant lives or has moved out of Washington State and needs assistance locating a provider. Other examples include an L&I claim involving medically complex conditions, or when there are other barriers impacting successful claim resolution.
As an L&I attorney representing work injury claimants, I have partnered effectively with NCMs on countless occasions to achieve results that benefit not only work injury claimants, but also L&I and other stakeholders. This is particularly true in Out-of-State cases, complex or catastrophic medical cases, and cases with other issues creating a barrier to appropriate claim progress.
How are Nurse Claim Managers useful in Out-of-State claims?
NCMs are instrumental in assisting us to obtain Out-of-State treatment providers. Usually, before we request assistance from a NCM, my staff undertakes to assist our clients with this process. However, due to the meager L&I fees for service providers, we are finding it more and more challenging to find willing Out-of-State treatment providers. Furthermore, we often find that despite our best efforts, treatment providers are turned off when a law office contacts them to inquire about providing L&I treatment to a work injury claimant. They usually assume our involvement means the claim is messy or legally contentious. This is often not the case.
Once my office has exhausted our resources trying to get an Out-of-State provider, we ask for an NCM to be assigned. In approximately 4 out of 5 cases, having a NCM assigned results in our ability to track down a willing Out-of-State provider despite our prior failed efforts. When a willing Out-of-State provider cannot be found, we are left with only one option: L&I must bear the expense of having the injured worker regularly travel to Washington State for treatment. Yes, this means L&I is paying for flights or other transportation, hotels, and meals, on regular intervals for work injury claimants to travel to Washington State for treatment. Again, in approximately 4 out of 5 cases, NCM involvement has saved L&I and work injury claimants from the expense and stress of travel to Washington for treatment.
Complex or catastrophic claims
When I say complex or catastrophic claims, I am referring to injuries that result in significant, often irrecoverable, disability. The best example I can give is an injury that results in quadriplegia. Treatment and care for individuals paralyzed by their injuries is incredibly complex. There are so many moving parts from acute treatment to long term treatment. During acute treatment, many families are unsure whether their loved one is even going to survive. Most workers do not have attorneys in these early, but incredibly stressful hours and days. NCM’s can help guide these families to understand the system and make informed decisions.
Families of work injury claimants will bear the load
Once the acute treatment phase has passed, the real work begins. Paralyzed work injury claimants require a team of medical providers resulting in a complex schedule of appointments. Simply managing and getting to appointments is a full-time job. For this, usually a family member must take on the role of a full-time caregiver or a professional caregiver is needed. NCM’s are incredibly skilled in connecting families with the resources they need to determine if they can provide care themselves or need assistance from professionals. A number of other challenges must be addressed as well, including but not limited to: finding appropriate transportation for a paralyzed individual (imagine trying to get a paralyzed individual into a small family sedan), making appropriate home modifications or helping families relocate if needed (imagine trying to bring a paralyzed work injury claimant home to a second floor apartment with no elevator), and obtaining all of the necessary durable medical equipment needed such as wheel chairs, toilet seats, shower accessories, appropriate medical bedding to prevent bed sores, catheters, and the list goes on.
Certainly, if the family elects to hire an attorney, we can help with some of these logistics. Yet, at the end of the day, we are legal professionals. We do not have the knowledge, skill or medical experience to help families with all of the medical logistics needed for a catastrophic injury. I know from personal experience that NCM’s spend countless hours in the early days of claims helping families get everything they need in place. There is no way $200 comes close to compensating NCM’s for the services they provide in this kind of setting.
The role of Nurse Case Managers in L&I claims with other barriers to progress
When I speak of other barriers to progress, I’m generally referring to medical complications that impact claim progress. For example, work injury claimants with underlying health conditions such as diabetes, COPD, pacemakers, thyroid disease, and more may need to coordinate care between specialists and L&I treatment providers before treatment progress can be made. For example, an injured worker with a pacemaker may need clearance from a cardiologist before surgery can be considered. Similarly, work injury clients taking medications for an underlying thyroid disease may now be facing adverse drug interactions for claim related treatments. The list goes on and on.
NCMs are particularly helpful in these situations because they can utilize their medical experience to ensure that appropriate coordinated care is occurring. Another example is when weight loss is needed for treatment progress. For example, medical best practices dictate that people must be under a certain BMI to be eligible for knee replacement surgery. If a work injury claimant needs to lose weight in order to have a particular treatment, then weight loss treatment is covered under the claim. However, only specific methods of weight loss are authorized. NCMs are an invaluable resource in helping work injury claimants find appropriate, authorized weight loss treatment programs, connecting with dieticians, and helping to monitor weight loss progress to ensure it remains on track. Similarly, NCMs are often instrumental in aiding in opioid addiction recovery under the medical treatment guidelines. Again, as attorneys, there are many things we can do to assist work injury claimants with all of these claim related issues. However, at the end of the day, since we are not medical professionals, there are things NCMs can accomplish with more efficiency and experiences than we can.
Cutting funding will have serious negative implications
In summary, claims involving catastrophic work-related injuries not otherwise being managed under the “Catastrophic Project”, work injury claimants that live or have moved out of state and need assistance locating a provider, medically complex condition(s), and or other barriers impacting successful claim resolution are difficult enough as they are. Historically, having access to experienced NCMs has made these challenging claims much more manageable for work injury claimants, their families, attorneys, and L&I alike.
The new fee schedule is going to gut the usefulness of the NCM program. I predict that any savings L&I may see by capping NCM fees at $200 per month will be eclipsed quickly by increased L&I claim costs. I understand the need to avoid excessive hours spent and overbilling, but the 75 hours of service per referral cap already accomplishes that. It is with an unnerving sense of dread for what this will mean for work injury claims that I must unequivocally say: I am incredibly disappointed in L&I. This new Fee Schedule is doing nothing to reduce to a minimum the suffering and economic harm suffered by work injury claimants and their families. In fact, I predict it will do just the opposite.