Elements Of Case Management

(1) Case management services shall include, but not be limited to, the following elements required in T.C.A. § 50-6-123 [Section 7(b) of Public Chapter 900]: (a) Developing a treatment plan to provide appropriate medical services to an injured or disabled employee; (b) Systematically monitoring the treatment rendered and the medical progress of the injured or disabled employee; (c) Assessing whether alternate medical care services are appropriate and delivered in a cost-effective manner based on acceptable medical standards; (d) Ensuring that the injured or disabled employee is following the prescribed medical care plan; and (e) Formulating a plan for return to work with due regard for the employee’s recovery and restrictions and limitations, if any. (2) A case manager shall not: GENERAL RULES OF THE WORKERS’ COMPENSATION PROGRAM CHAPTER 0800-02-07 CASE MANAGEMENT (a) Prepare the panel of physicians or influence the employee’s choice of physician; It is permissible for the case manager or case manager assistant to present the form prepared by the adjuster to the injured worker as long as they do not influence the injured worker’s decision; (b) Determine whether the case is work related; (c) Question the physician or employee regarding issues of compensability; On behalf of the adjuster, the case manager and case manager assistant may request that the physician address causation in their medical notes; (d) Conduct or assist any party in claims negotiation, investigation, or any other non- rehabilitative activity; (e) Advise the employee as to any legal matter including settlement options or procedures, monetary recovery, claims evaluation, or the applicability of the workers’ compensation act to the employee’s claim; (f) Accept any compensation or reward from any source as the result of settlement; (g) Discuss with the employee or physician what the impairment rating should be; (h) Reschedule medical appointments without first discussing the scheduling change with the employee; (i) Refuse to provide case management reports to parties to the claim; (j) Assist in any way in recording the employee’s activity for the purposes of disproving the employee’s claim; (k) Deny or authorize treatment for the purpose of guaranteeing prepayment or precertification; (l) Refuse to comply with the facility or provider’s office staff in regards to specific policies and procedures related to case management; or (m) Refuse to allow patient/physician privacy during the medical examination. (3) Any case manager or case manager assistant that commits any of the actions provided in paragraph (2) may be assessed a civil penalty of no less than fifty dollars ($50) and no more than five thousand dollars ($5,000) for each action committed. The Administrator shall have discretion to suspend the registration of any case manager assessed more than three (3) penalties in any two (2) year period for up to sixty (60) days. The Administrator shall have discretion to suspend the registration of any case manager for up to one (1) year for offenses after the three-penalty limit within any two (2) year period. Any case manager suspended by the Administrator pursuant to this paragraph shall not provide case management services to any employee receiving treatment for a workers’ compensation injury during the period of suspension. Any case manager or case manager assistant who has had their registration suspended by the Administrator who provides case management services during the period of suspension shall be assessed a civil penalty of no less than fifty dollars ($50) and no more than five thousand ($5,000) for each action committed and shall have their registration suspended for an additional six (6) months. GENERAL RULES OF THE WORKERS’ COMPENSATION PROGRAM CHAPTER 0800-02-07 CASE MANAGEMENT (4) Failure to submit the required case management notification form(s) within thirty (30) days of the initial meeting and within thirty (30) calendar days of closing the case may result in a civil penalty of one hundred dollars ($100) per occurrence. (5) It is the intent of the case management system to expedite communication and provide a conduit for improving the efficiency and timeliness of care in all cases where case management is undertaken. To that end, all providers, injured workers, adjusters and employers should utilize case management to its fullest extent and provide expedited responses to the case manager’s requests.