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?

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?

Who is paying you?

Can my employer make me to return to work when I still have pain?

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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