Formula for “great” work: nurse applies it in insurance business

by • September 1, 2008 • UncategorizedComments Off on Formula for “great” work: nurse applies it in insurance business1868

© 2008 The Medical-Legal News
By Nancy Reisner, RN, CLNC


One thing that has always impressed me about the field of nursing is the unlimited opportunities and roads you can choose to go down. When I was in school, my plan was to work in a hospital at the bedside. I really didn’t stop to think of other options and I certainly had no idea that in 20 years I would need to use a map to find where I am today.
As most nurses can attest, one job leads to another. You take the skills you’ve learned and apply them to your next position, always building on your past experience. It’s sometimes surprising how these skills can cross over into very different applications at times. Much of what we do is to educate. We spend significant time educating our patients, our customers and ourselves. We learn even while we are educating. For those willing to “stretch” those skills, some very interesting jobs or even business opportunities can lie ahead.
My road has been a fairly winding one. I’ve always thought this helped to make me more “well rounded.” I’ve had a nice variety of past nursing positions that have led me to where I am now. Today I am working as a full time legal nurse consultant and have been certified for the past 10 years. I’ve always felt very strongly that education and certification in the specialty area you choose helps equip you to go forward and also assists in marketing yourself more effectively in that area. I have tried being a business owner and found that I like the support and camaraderie of a company and coworkers. I appreciate having the infrastructure that a larger company can provide (e.g., marketing staff and billing assistance). Fortunately, I have been able to team up with a company that shares my passion for this type of work and has supported and encouraged the development of a legal nurse product.
As with general nursing, there are a wide variety of opportunities within the field of legal nurse consulting. The obvious role that we all train for is working directly with plaintiff and defense attorneys. This opens the door to a variety of types of litigation (medical malpractice, personal injury, products liability, managed care cases, toxic torts, criminal abuse, DUI cases, etc.). However, anytime there are medical records, there is an opportunity for a legal nurse to be involved, and the law office is not the only place we can be marketing to.
I have found my legal nurse experience has led me in many directions, one of them being the liability insurance industry. This is not a new area for nurses, as nurses have been providing medical record reviews for insurance companies for years. However, when a legal nurse consultant provides the review, you have someone who is knowledgeable with the litigation process and the theories of liability. The legal nurse is able to apply his or her fine-tuned screening skills and provides professional reports, chronologies, bill reviews and medical research to support an opinion. The legal nurse also understands the importance of looking at the entire “picture” and providing an informed and factual document that the medical records support.
The adjusters I work with are very experienced, but frequently have questions about the injury or the treatment that was sought. They are extremely busy people frequently faced with some very medically complex files. On each case, I work with the adjusters to find out what their concerns are and determine what type of product will best meet their needs. The main question an adjuster generally asks is, “What really happened at the time of the claimed injury and what am I responsible for?”
During the course of the review, essential missing records, pre-existing diagnoses and treatment unrelated to the claimed injury are identified. The report outlines these issues, and notes the supporting documentation. Frequently, this information results in substantial cost savings for the adjuster. The report findings are utilized during the bill paying process and at the time of settlement. The adjuster can use the legal nurse’s report and feel confident that he or she knows the facts of the case and how this impacts the claim.
In my past experience I have found the legal nurse review can be extremely beneficial for those adjusters trying to adjudicate or resolve a liability claim. A legal nurse review should not just be reserved for the most complex cases, although that is where we can have the greatest impact. I enjoy equally the adjuster who calls to ask a question, or who sends me a few pages of bills or records to look at and discuss. This is all a part of the entire process of meeting the needs of your customer and, in the process, developing quality relationships.
If the legal nurse provides a workable product that meets the needs of the adjuster, answers the questions of the case in an understandable manner and notes the supporting documentation, you will have a good work product.
If the legal nurse strives to provide quality service and a superior work product, truly cares about meeting the needs of the adjuster, understands that every dollar counts — including what the adjuster is spending for your services — is passionate about finding the truth based on the available facts, has a keen eye for reviewing the medical records and provides sound nursing opinions based on this, then you will have a great work product.
I base my business on this last paragraph. I care about my customers and I care about the claimant’s files that I review. In the end, whether it’s good news or bad news, it’s important that the adjusters know where they stand. It’s my goal to help them take that stand. •

Nancy Reisner, RN, CLNC, has 23 years of nursing experience with 10 of those years as a Certified Legal Nurse Consultant®. She has been employed with The Alaris Group, Inc. for the last five years.

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