Case Management?

[FLMommy]

What is the name of your state? Florida

I am not sure if this is going to contain a legal question per se, but I am sure there is someone here knowledgeable on the subject that can give me some answers. Excuse me if this is drawn out and contains unnec. info. Just trying to present as many factors as possible.

A year ago, our daughter was born 10 weeks premature and despite a benign course in the NICU (No oxygen required) she was diagnosed with Hydrocephalus. Hydrocephalus was discovered after a routine head ultrasound while she was in the NICU. According to her neurosurgeon she acquired it after a brain hemmorhage that occured slightly before, during, or right after her birth and left some scar tissue in one of her vetricles.

She's had 2 brain surgeries, the first one to place a subgaleal shunt, which was replaced by a VP shunt. She's done great so far considering the failure rate of a VP shunt during the first year is 50%. She's been receiving great care by her pediatrician, neurosurgeon, and on top of that is part of the FL Early intervention program. The latter have recommended physical and occupational therapy for her, and after evaluations, and prescriptions from the ped. she receives PT 2X/wk and since 2 weeks ago, OT 1X/wk. The deductibles for these services are paid by the FL EI program.

According to our Health Insurance policy, they offer something called "Case Management" - I am surprised they didn't contact us sooner to offer it to us, considering our daughter's history, but this morning I got a call from an RN - I guess she works for the Ins Company. She's calling back in a few hours, I wasn't able to talk to her.

It is up to us whether we use this service or not. The policy says they will draw up a plan of care and if the Plan, we, and her primary physician agree, the "Plan will reimburse for Medically Necccesary expenses as stated in the treatment plan, even if these expenses would normally not be paid by the Plan."

Here are my q's: Is it wrong of the to assume that since this person works for the Ins. Co. she is out for the benifit of the Ins. Co? Our daughter is well taken care of and followed. It took our Ins. Co. 6 months to start paying the PT/OT place, according to them because they hadn't received the Dr's prescription etc. (I called the PT/OT place several times, and they even gave me the name of the person they talked with at our Ins. Co. who confirmed they had all the paperwork). I find it funny they call now... could it be because they don't want to pay the 60% (It's an OON provider) for 2X PT, 1/2X OT and want to do their own "eval"? How do they evaluate my daughter from a distance?? It's nice to know they will pay for everything according to the plan of care if we participate, but unless they also pay for the deductible when our daughter needs major medical care (like an MRI or other brain surgery), it's not really of extra benefit to us. Does anyone know if the quote at the end of the previous paragraph also means they cover deductibles? Do I have to watch out for "selfish" motives of the Ins. Co? Also, if we agree to this plan, and after their plan of care is not what we agree with, can we opt out without them denying us coverage that is not according to their "pan of care?"

Thanks for reading all this info. Thoughts and advice would be greatly appreciated.

 

[lealea1005]

What is the name of your state? Florida

According to our Health Insurance policy, they offer something called "Case Management" - I am surprised they didn't contact us sooner to offer it to us, considering our daughter's history, but this morning I got a call from an RN - I guess she works for the Ins Company. She's calling back in a few hours, I wasn't able to talk to her.

It is up to us whether we use this service or not. The policy says they will draw up a plan of care and if the Plan, we, and her primary physician agree, the "Plan will reimburse for Medically Necccesary expenses as stated in the treatment plan, even if these expenses would normally not be paid by the Plan."

Here are my q's: Is it wrong of the to assume that since this person works for the Ins. Co. she is out for the benifit of the Ins. Co? Our daughter is well taken care of and followed. It took our Ins. Co. 6 months to start paying the PT/OT place, according to them because they hadn't received the Dr's prescription etc. (I called the PT/OT place several times, and they even gave me the name of the person they talked with at our Ins. Co. who confirmed they had all the paperwork). I find it funny they call now... could it be because they don't want to pay the 60% (It's an OON provider) for 2X PT, 1/2X OT and want to do their own "eval"? How do they evaluate my daughter from a distance?? It's nice to know they will pay for everything according to the plan of care if we participate, but unless they also pay for the deductible when our daughter needs major medical care (like an MRI or other brain surgery), it's not really of extra benefit to us. Does anyone know if the quote at the end of the previous paragraph also means they cover deductibles? Do I have to watch out for "selfish" motives of the Ins. Co? Also, if we agree to this plan, and after their plan of care is not what we agree with, can we opt out without them denying us coverage that is not according to their "pan of care?"

Thanks for reading all this info. Thoughts and advice would be greatly appreciated.

So glad to hear your daughter is doing so well and receives excellent care by practitioners you trust and are comfortable with.

This is just my opinion based on years of experience dealing with health insurance companies...I am not a lawyer.

Insurance companies are in business to make money.

Although the concept of case management is a good one (all information passes through one spot so there's contiuity of care), you have to be very careful. Most times, when Case Mangement has taken over a case, they start dictating which medications, Doctors and other practtitioners, and what treatment they decide are "medically necessary". Also, there's the problem of getting treatment plans and referrals "approved" by your case manager in time for your daughter's scheduled treatments/testing/vists to the specialists. Often, patients are told (just as you were) that the information was not sent by the PCP's office, or it's not "complete", or "it's in review", etc. Paperwork and the beaurocracy become overwhelming for both you and all of your service providers and your daughter will be the one who loses.

You are very happy with the way things are and the insurance company is covering services, even if they are out of network.

My advice is....if it ain't broke don't fix it!

Hope this info helps.

 

[FLMommy]

Thanks so much lealea. After your reply we received a letter from the company handling the case management stuff (after doing some googling I found out they're all under the same umbrelle anyways, figures) which stated that if we did not participate in case management we could be denied benefits. Finding that highly unlikely and a "breech" of policy, my husband contacted our ins. comp. and they said they didn't contact anyone form Case Management and that it won't affect out benefits in any way. Taking into account your reply our own doubts on whether to participate or not, we decided not to. Our daughter is taken care of for time being and all her docs are helpful answering our q's. Thanks again, and I am sorry this reply is so late!

 

[Job_Hunting]

FLMommy,

I work in a PT facility, and you should know that the case management programs do NOT cover your deductible or co-insurance. This is strictly a way for them to save on costs. Also, what they will do is delay payment to the facility/doctor, then contact them several months later and ask if they will (Out of Network) negotiate a fee. Yes, the negotiated fee will include services that may otherwise have been denied, but your ded and co-shares will be deducted from their negotiated amount and considered your responsibility. It could; however, save you a little out of pocket if the docs agree to that lesser amount.

 

[FLMommy]

Thanks JH, I appreciate your input! Fortunately the state of FL runs a pretty good developmental program (for 0-3 yr olds) and they cover all our deductibles when it comes to her PT and OT, which is HUGE! If this was not the case, according to your info it might have bene better for us financially to go with the Case Management. Thanks again.

 

[jezziebelle]

I want to offer a different view. I am a registered nurse case manager for a payer entity. I certainly cannot speak for all payers or case managers, but I want to suggest that case management by a payer be given a chance. My many clients would agree. I understand the suspicions in today's health care environment, but suspicions cannot be dispelled without giving the service a try.

Of course a payer entity case manager is going to have an obligation to protect the Plan. But, as a health care professional and a member of the Case Management Society of America I can say that the philosophy of payer case management is: To be a patient advocate, to provide the best patient care and ultimate patient outcome by maximizing patient benefits, and to also protect plan assets. All health plans are going to consider Medical Necessity when providing patient benefits. Without case management, medical service codes, computers, and "bean counters" are going to be the decision makers. With case management, a health care professional will be involved. Every good health care professional knows that long-term improved patient outcomes improve costs, even if the initial expenditures are greater. Every plan, case manager, and payer will be different, but the goal should be the same: Provide the best patient care resulting in the best outcome, at the lowest possible cost. Notice that lowest possible cost comes last, because if the first two are accomplished, the latter follows.

Many situations lend themselves to the services of a case manager. A case manager can recommend that excluded services may provide better outcomes for the client and result in lower costs short-term and / or long-term. CM can negotiate contracts with out of network providers that save the plan money while also reducing patient out of pockets, such as Usual, Customary, & Reasonable charges. Physicians often refer patients to their alma mater without considering the network / financial impact of such referrals. CM's can direct patients to network providers that have equal or better services at reduced cost to both patient and plan. I have intervened to keep patients in the hospital when the hospital was ready to discharge with poor in-home planning until appropriate planning was in place. I have negotiated after the fact with out-of-network providers to save a client over $20,000 in out of network expenses and at the same time saved the plan money. I have sucessfully had clinical trials and investigational / experimental services covered, because they they proved the best clinical and cost plan of care. I have insisted that a brain injured teen-ager be placed in rehab and found the appropriate rehab to take him rather than let him go to a nursing home (he has a job now). I sit and go through client's bill's with them, I call the collection agencies when a patient responsibility is past due, I monitor their lifetime expenditure limits. I laugh with them and I cry with them. I go to their homes and the hospital. Unfortunately, I even go to their funerals. Nearly all of my clients gave me the suspicious eye and ear the first times we spoke. But, given the chance, the vast majority of my clients call me for EVERYTHING. Many times I end up providing service for all the family and sometimes even the friends they refer to me when they don't really need a case manager. I've watched my co-worker case managers accomplish some really amazing things. I've watched case managers for other payers and providers accomplish some really amazing things. Not every situation evaluated by a case manager ultimately needs cm. But, I hate to see anyone refuse a potentially valuable service and relationship without at least giving it a chance. Did anyone ever get the "let me transfer your call" to 4 or 5 people response when calling the insurance company? How about one call to your case manager instead? If it doesn't work out, don't use the service. No harm, no foul.
Jezziebelle