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Health Insurance Case Manager "offer"


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My health insurance has had a nurse "case manager" contact me-- phone msg and letter to "help" me to "play an active role in my health care," and make sure my "treatment plan" makes sense. ???

Am I right to be cynical and think little good can come of this? My hunch is that my ppo insurance has noticed that I'm costing them a lot. They can't dump me, so they want to "help" me to cost them less.

I was actually a little surprised, as my medical ordeals have been somewhat less recetnly. I haven't been to the ER since October, no surgeries in three years. So I don't know if they're looking at a multi-year trend? I do get prolotherapy injections regularly which are expensive...

Any experience with people like this? It's hard to imagine that some hired gun for the company would have much useful to add, given that I have non-typical health issues (eds, ncs/pots, weird allergies, tuberous sclerosis, and some strange symptoms probably related to the above...)...

No where did it say I had to speak to her, just a strong suggestion. So I think I'm not going to. If she tracks me down, I'll have to think about how to respond...

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I used to be a Utilization Coordinator for a health insurance company. I worked directly, one-on-one with the case manager. When I got sick they did everything to move heaven and earth to help me, but then, they watched my ordeal - and had no better luck than I did talking to the doctors.

More than likely, a diagnosis code popped up in a computer and kicked you onto the case managers desk - and yes, it can take several months for it to do that, or perhaps she has had a stack sitting on her desk and has just now got around to contacting you.

Contacting her might smooth your way to several things, such as getting a few things approved quicker. She probably just needs to hear from YOU what is going on. You are probably quite a novelty and they don't know what your needs are.

I remember once a code popped up on a lady ho was having a hip replacement - the code was for breast cancer - she was having a hip replacement. Seems that while she was in the hospital for her hip replacement her oncologist (her words) "popped his head around the door and said hi!" I carefully questioned her about how long they talked, did he change any of her meds and so forth. Seems he made a 3-4 minute visit and turned a bill in to us for $250! He called it a follow-up.

We had one woman who we could not contact - but kept getting requests for a motorized wheelchair.... nothing in her records that we could see justified it and, despite letters and phone calls, we could not get in touch with her. Finally, after almost a year, her son called. His mom had MS - but she was opting for alternative medicine, was paying out of her own pocket, and it didn't show up on anything we had. We approved the wheelchair because it was obviously medically justified.

I would say talk to the case manager, see what she has to say. You can always refuse her services - approach it with a "what can YOU do for me" attitude.

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for me the case managers at my insurance company have been nothing but wonderful. i'm a very educated consumer, i.e. i know my 150page policy well (not just the 2 page summary that most people peruse), but truly i can't come up with one negative in terms of the two case managers i've worked with. i only wish i'd requested one sooner (rather than waiting for one to be "given" to me). for me this means i have someone who i can call & speak with directly who actually knows about me & my situation rather than calling the generic customer service number & getting whoever answers. generally they are RNs as well which means that they are better able to understand what is actually going on medically...obviously they may not know anything about your situation but they have the medical training to understand information that is presented/explained to them (as opposed to a generic customer service rep with little/no medical knowledge). they have helped me when i've had issues with providers, they've been able to expediate approvals/pre-approvals for things, researched issues for me that have been more than a little out of the box, etc.

i don't blame you for being skeptical but i would certainly give it a chance as you might be pleasantly surprised. i know that insurance can be the "bad guy" but it's not always. and while i don't doubt that there are some bad case managers out there, you may just end up with someone who truly is trying to help you.

if your experience is half as good as mine has been in this arena you'd come out on top...

:) melissa

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Interesting-- I guess I'd become cynical. So is there anything you'd recommend I not say or volunteer-- or just lay it on the line? One thing I'm concerned about is they've been paying for some relatively alternative stuff (prolotherapy), and am afraid that if they think too hard about it, they'll start refusing to pay...

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I have to agree with the benefits to having a case manager. I was on daily iv therapy for a year and a half. Occasionally, a nurse would call to check on me (from the insurance company). I was able to teach a few nurses about dysautonomia, the importance of iv fluids, etc. I was able to justify my requirement for the home iv supplies to them and they were in total agreement. Having the fluids at home kept me out of the hospital which would have been much more expensive. So, be honest- explain why you need particular treatments. Chances are whatever treaments you are using to keep you functional are less expensive than a lengthy (or even a brief) hospital stay.


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My case manager was also awesome--I got bumped to one because I have asthma, and they have case managers assigned to all asthmatics who'd be hospitalized for asthma related issues (I'd gotten pneumonia). She helped to get me things that normally my insurance does not cover, including a nebulizer.


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