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Adventures in Insurance Company Nurse Consulting

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When people ask me where I work or what I do for a living, I often get a puzzled look when I say that I am a legal nurse consultant for a global, Fortune 100 insurance company.

I have quickly learned to streamline my potentially lengthy answer to state that I provide proactive medical expertise to personal & commercial lines claims adjusters, managers, & defense counsel on the medical portion of their auto & general liability bodily injury claims. I’ve been told that sounds way more impressive & encompassing of my daily responsibilities than explaining how I review medical records & bills, which can sometimes come across as boring & tedious to the average person.

I seldom have a routine or mundane day as my job description includes everything from record review & research to education & roundtables revolving around similar premises of assisting my 37 local & remote claims reps of various experience (less than one year to over 25 years) in determining whether the mechanism supports the injuries (alleged vs. real), if the treatment was medically reasonable & necessary based on healthcare guidelines, identifying critical missing records, forecasting potential costs of future treatment & wage loss, & providing my recommendations in resolving the claims in a fair settlement that both the Claimant & insurance rep feels is mutually equitable.

Occasionally, I am asked to work on special projects involving developing education & writing newsletters for specific injury or treatment trends, company or claims rep training & events, & national nurse newsletter committee participation. Because my current nurse consultant role is relatively new after completion of a successful three year pilot, it is an exciting time to work in a position that will continue to evolve as our valuable contributions are noticed & encouraged.

Although many of the claims I review involve evaluating similar soft tissue injuries & questionable excessive chiropractic or PT treatment, no two claims are ever the same. I am personally grateful that the nurses aren’t directly involved in the liability & coverage issues or monetary aspects of reserve setting or claims resolution & that my focus is on the medical aspect where I feel most knowledgeable & confident.

However, I have learned a great deal about the value & importance of liability, varying state laws & statutes, negotiation, mitigating arguments, fraud, bad faith allegations, & how I can apply my 24 years of healthcare experience to all of these variables to result in fair claims resolution.

I have also learned more about ortho. & neuro. anatomy & physiology than I would have ever thought possible. I have to take on the daily challenge to remain objective regardless of the perception of all involved parties including the Claimant, claims reps & their managers, plaintiff & defense counsel, special investigations services (SIU) & even myself as each claim may not always be what it seems until after a thorough investigation of the facts & medical review is completed. One of the most critical things I have learned in my role is that insurance companies are not bottomless checkbooks for Claimants & they really do perform thorough investigation & review prior to beginning the negotiating process.

The serious part of my job involves reviewing & educating the claims reps on the medical effects of severe injuries such as traumatic brain injuries, facial scarring of children from dog bites, spinal disc herniations requiring risky surgeries, permanent impairments, & exacerbations of complex pre-existing degenerative conditions. Fortunately, the majority of the claims I review do not involve significant injuries.

Needless to say, my days are never boring & my thought process when working with the reps, unit managers, SIU, & defense counsel often has me thinking & actually saying “you simply cannot make this stuff up!” I have been involved in reviews of some of what my co-workers & I have perceived as claims that ‘had to be shared’.

One claim involved several phone calls to a Claimant to inquire what exactly he wanted from us regarding his claim that “There was hair in my pork rinds!” The claims rep was so impressive & diplomatic in her calm & patient negotiations that “pork rinds are made from pig skin, sir” & “yes sir, pigs are mammals & do have hair.” Another claim we called “Claimant alleges getting herpes from under where?” involved a young Claimant who purchased underwear from our insured’s department store & alleged that the genital herpes diagnosed in the ER several days later was caused by wearing the newly purchased underwear. Another claim was a fraudulent claim that I worked extensively on named “Why spell check is a good thing” & involved a woman who alleged multiple cervical & lumbar ruptured discs that required multiple surgeries from a metal lid of our insured’s sandwich shop’s ice machine lightly hitting the bridge of her nose as observed by several witnesses. This minor injury resulted in a small laceration that did not require any medical attention in a Claimant that I found (through my review of voluminous medical records) had multiple falls from her horse & other prior injuries that she never anticipated we would discover. A real note in our system stated “nurse review critical as Claimant alleges ruptured dicks from metal ice machine lid falling down & hitting her nose.” I guess we all have to have a good sense of humor with what we do every day!

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