What You Need To Know If You Are Assigned A Nurse Case Manager For Your Insurance Claim

20 November 2015
 Categories: , Articles


A nurse case manager might be considered a helpful benefit as part of the insurance compensation in an accident claim. However, sometimes having a nurse case manager can seem more like an invasion of privacy into your health and life in general. If you've been in an accident and have been assigned a nurse case manager (or are expecting to), here are a few questions you may have. 

What are the roles of a nurse case manager? 

Nurse case managers perform a variety of tasks to help you get back on your feet again from your injuries. Here are a few things your nurse case manager may do: 

  • facilitate  meetings between your claim adjuster and your health care providers
  • schedules your appointments with your health care providers 
  • monitors treatments and services to see if they are being followed through

Why is a nurse case manager hired? 

While the purpose of these tasks is to assist you in recovery and rehabilitation from your injuries, the primary purpose is to save money for the insurance company that is paying your medical bills. Nurse case managers aren't always necessary, but they can be immensely beneficial to insurance companies for cases in which prolonged or life-long medical treatment and rehabilitation are necessary.

They can also be hired by insurance companies when claim adjusters or lawyers raise questions as to whether or not the claimant is actually seeking medical care, following through with treatment to improve their health, and/or actually really injured. 

Who hires nurse case managers? 

Given that nurse case managers are typically hired primarily to cut down on the medical costs of the insurance company, the claim adjuster of the insurance company is usually the one who hires the nurse case manager in a case. However, sometimes they can be hired by other entities that are involved in the case, such as the no-fault insurance company for a car accident or an employer for a workers' compensation case. 

Wouldn't that mean there's a conflict of interest? 

Even though nurse case managers report to the entities who hire them, they are supposed to perform their duties without a bias. For example, even though he or she is hired to make sure your treatments progress along in a timely manner, they cannot hurry the progression of your treatments simply to save money for the insurance company.

Nurse case managers are not in charge of your recovery and rehabilitation. Therefore, they cannot tell your health care providers how your treatment should go. But they can discuss your treatment with your claim adjuster and health care providers for the reports they write up for the insurance company.  

Wouldn't that be a violation of HIPAA? 

These discussions between your insurance claim adjuster, nurse case manager, and your health care providers fall under HIPAA privacy standards. Before these discussions can take place, you will be asked  by your physicians to give consent for them to share information with your nurse case manager.

To do this, you will be asked to read and sign a disclosure allowing the authorization of the disclosure of your medical information for necessary purposes. If you do not give consent, the nurse case manager cannot discuss your case with your health care providers. Ask your accident lawyer if and when it is appropriate to deny consent based on the specifics of your case. 

What can be done if you feel your privacy is violated? 

If anyone violates your HIPAA rights to privacy by discussing your case without consent or overstepping the boundaries of the consent, they could risk 10 years imprisonment and fines of as much as $250,000. Speak with an accident lawyer, such as J D'Agostino & Associates, P.C., if you feel your privacy has been violated.