Ethical Considerations for Case Managers

Ethical Considerations for Case Managers in Michigan

A review of relevant professional literature reveals that increasing attention is being paid to the ethical issues of case management. The literature recognizes that case managers hired by insurance companies have important obligations to patients that should transcend loyalty to the insurance company who hired the case manager.

A Case Manager’s Priority Must be the Patient

The Case Management Society of America (CMSA) promulgated “Standards of Practice for Case Management” in 1995. These standards contain numerous references to a case manager’s ethical obligations to the patient, regardless of who hired the case manager. For instance, at page 9 of the CMSA Standards, the following is stated:

The case manager should represent the client’s interests by advocating necessary funding, appropriate treatment and treatment alternatives, timely coordination of health services, and frequent re-evaluation of progress and goals. Recognizing that client advocacy can conflict with a need to balance cost constraints and limited healthcare resources, the case manager should continuously self-evaluate his/her decisions with the intent to uphold client advocacy.”

Similarly, the CMSA Standards state at page 19:

The case manager’s central focus is on the client and his/her family. Ideally, the case manager should advocate both for the client and for the payer to facilitate positive outcomes. However, when a conflict arises, the needs of the client must be the priority. The case manager will advocate for the client/family at the service-delivery level, the benefits-administration level, and at the policy-making level.”

Read as a whole, the CMSA Standards clearly indicate that the case manager’s primary responsibility and loyalty is to the patient. If the case manager has to choose between saving money for the insurance company or promoting and enhancing the care, treatment, and rehabilitation of the patient, it is the patient’s interests that must control.

This may mean that a case manager will have to recommend or advocate for a particular level of care and treatment that the insurance company does not believe is necessary or required. A case manager who places his or her own economic self-interest above that of the patient in this situation is not engaging in conduct that is consistent with the ethical standards embraced by the CMSA.

In 1996, the CMSA issued a “Statement Regarding Ethical Case Management Practices,” which further emphasizes the principle that the case manager’s primary role is to be the patient’s advocate. The Statement provides in pertinent part:

Case management is guided by the principles of autonomy, beneficence, nonmaleficence, justice and veracity.

Autonomy is defined as ‘a form of personal liberty of action when the individual determines his or her own course in accordance with a plan chosen by himself or herself. (Beauchamp and Childress, 1979, pg. 56). This is the fundamental ethical principle of case management practice. The role of case manager as client advocate arises from a commitment to the concept of client autonomy. The needs of the client, as perceived by the client, are preeminent. Thus the client is primary relative to decision making. The case manager collaborates with the autonomous client with the goal of fostering and encouraging the client’s independence and self determination. This leads the case manager to educate and empower the client/family to promote growth and development of the individual and family so that self advocacy and self direction of care is achieved. This implies informing and supporting the client in their options and decisions related to their healthcare.”

The Ethical Duties of the Case Manager

The ethical constraints imposed upon case managers include, but are not limited to, informing the client if the case manager has reason to believe that the client’s rights have been, or are about to be, violated or compromised. A case manager cannot ethically sit back and do nothing when he or she is aware that the insurance company has taken action that is, or may be, inconsistent with the insurer’s legal obligations under the Michigan No-Fault Statute.

In this situation, the case manager has an ethical duty to inform the patient that the patient may need to assert and protect his or her rights under the Michigan No-Fault Act. In this regard, the CMSA Standards of Practice set forth certain obligations of the case manager with respect to the client’s legal rights. Regarding legal issues, the CMSA Standards state in pertinent part at page 18:

The case manager will: . . . 3. Maintain current knowledge and understanding of applicable state and federal laws protecting the rights of the client and act in accordance with such laws . . . 6. Utilize appropriate and reliable resources for the resolution of legal or other relevant questions and issues. 7. Maintain current and appropriate knowledge and understanding concerning benefits and benefits administration that specifically pertain to case management services.”

Regarding ethical issues, the CMSA Standards further state, at page 19:

The case manager will: . . . 2. Act as a client advocate to the end that information is provided to the client to make an informed health decision and promote informed consent. . . . 5. Utilize appropriate and reliable resources and consultation to help formulate ethical decisions. . . .”

The ethical obligation to advise a patient that a no-fault insurance company may be acting in violation of the patient’s legal rights is an issue that appears more frequently than one would imagine. How many times has a case manager observed a situation where a catastrophically injured patient was entitled to more attendant care than the no-fault insurer was providing? How many times has a case manager seen replacement service expenses not claimed but clearly due and owing? How many times has a case manager noticed that a patient may be entitled to certain work loss benefits that were not properly calculated or taken into consideration?

In these situations, if the case manager is properly discharging his or her ethical obligations under the CMSA Standards and other applicable ethical principles, the case manager should, as the advocate of the patient, inform the patient of the need to protect his or her legal rights. Many times case managers do exactly this. Other times, unfortunately, they do not.

Obligation of a Case Manager to Inform a Patient of Treatment Options

In the case of Wynn v State Automobile Mutual Insurance Co, 856 F.Supp. 330 (1994), the United States District Court for the Eastern District of Michigan ruled that under the Michigan no-fault law, neither the automobile insurance policy nor the Michigan no-fault law imposed a legal duty on the insurer or its agents to act as the insured’s advisor and inform the insured of benefits covered by the contract or the statute.

The insurer’s agent in this case was a case manager who allegedly did not give proper advice to the patient regarding medical care and the patient did not receive the course of treatment recommended by the patient’s treating physicians. In holding that the insurance company and case manager do not have legal liability to the patient in this situation, the court noted that, “If medical experts recommended a course of treatment, plaintiff should have sought such treatment and then requested reimbursement from Mutual Insurance.” 

The case did not, however, address whether the case manager had any ethical obligations to the patient in this situation or had any independent liability as a fiduciary. Moreover, the case is not a Michigan appellate case and therefore, has no precedential value.

Case Managers Ethical Obligation of Trust with a Patient

Another disturbing ethical matter involves case managers who testify against their patients. In one recent case, the author observed a case manager testifying against her patient in a lawsuit filed by the patient against his no-fault insurance company seeking an increase in attendant care benefits.

At trial, the insurance company called the case manager as its principal expert opinion witness to dispute the plaintiff’s claim that additional attendant care was required. Needless to say, the claimant was distressed to see his case manager take the witness stand at trial and give testimony that was in direct conflict with the patient’s claim.

Case managers who solicit a patient’s trust and who then permit themselves to be used as hired expert opinion witnesses for insurance companies in litigation disputes involving the very patients whose interests they are obligated to advocate, are treading perilously close to engaging in conduct that is inconsistent with their professional ethical responsibilities. Case managers should, whenever possible, avoid these situations.