Information on "case manager" for insurance?

[OutlanderALS]

The provider for my trilogy asked if I have a case manager with my insurance (Medicare Advantage Plan). Can anyone offer information on this as to whether pals should go this route? Or how this even works? I wanted to ask in the forum before inquiring with the insurance people. Thanks for any enlightenment.

 

[lgelb]

It works like this: you call and ask to be assigned a case manager. In theory they are at least RNs. I can't guarantee what your plan does. What is your network? That person, if good, can be a help in getting things approved more speedily. Basically, paperwork goes through (usually a) her. But if s/he is under strict targets, she could also be a roadblock.

If you are not currently doing anything big-ticket that you need help with, you can always tell the DME "no, I don't," and regroup if there are issues. It's not required or anything. They just wanted to know if there was a person they could call or if their bills are going into the regular queue.

 

[KarenNWendyn]

I was never under the impression this was very helpful. It’s driven by the insurance company rather than by the team of doctors and other providers actually caring for you. What is the insurance company’s agenda in setting this up? They don’t have access to your medical records, just billing codes. I always figure that if you have questions, call your doctor first. You might end up speaking to the nurse or MA, but they will communicate with your doctor if there are concerns.

 

[lgelb]

The agenda is not fixed. In our case, with a Blue Cross plan, the case manager was instrumental in expediting our wheelchair order given an extremely indifferent DME, and getting the seat elevation feature fully reimbursed. A benign reason for the payer [I worked for one] to have case management is that admin costs, back and forth, are lower when complex people who will otherwise contact the general call center, have a specific person to call.

The case manager can help herd cats, avoid duplication and flag discrepancies that delay treatment/reimbursement.That is why I suggest everyone not getting what they want when they want it check it out. It can be a shorter distance between two points.

The case manager does not pretend to represent any treating clinicians, though s/he may interact with them. But like I said above, just like all docs aren't created equal, neither are case managers.

 

[Kristina1]

I had a similar experience to Laurie. I have BCBS. I never asked for a case manager, but one day we just got a phone call from hher and she said she was our case manager and asked how she could help. We asked her to help with the wheelchair process and she did. At one point our Numotion guy was being vague and not answering emails. One email to her and same day we got a full status report and she intervened to speed things up.

 

[nona]

I have had a lot of help from my case manager. She is an RN who works both for the medical center and my insurance, Harvard Pilgrim Stride. She has become my go to person. I'm sure the insurer has ulterior motives but so far it's working out for me.

 

[OutlanderALS]

Thanks for all of the responses. I am not yet, thankfully, into the big ticket items. But the clarification on how this might work with a case worker, is very helpful. Thanks again.