Case Managers Navigate the Road to Recovery



I work with nurses every day, and I’m one, too. We don’t work in a hospital or doctor’s office, but for an insurance company in an area called case management. We help patients in complicated health situations navigate the road to recovery.

Health insurance companies use case managers to make sure the patient is getting the medically necessary, quality care he or she needs and that it’s delivered as effectively and efficiently as possible. It’s offered at no cost, is confidential and voluntary, and you may opt out at any time. The service does not affect claims payments or benefits.
 
One of our nurses, Amy Rodrick, recently worked with one of our members who had suffered a stroke and required surgery to remove a clot.  She faced days of hospitalization and rehabilitation. A frightening experience for anyone.
 
That’s where Amy came in. She worked with the patient and her spouse so that they better understood her condition and her treatment and rehab options. She worked with them to prepare a list of questions to ask the doctor, so they were fully informed. She also helped them understand their health insurance benefits. 
  
It’s important to note that case managers do not replace care from doctors and other medical professionals. Think of a case manager as a patient advocate. With their medical experience, they can help explain confusing medical terms, review your treatment options with you, cut through red tape and reach out to see what options and services are available to you.
 
For the next several months, Amy called the patient and her spouse regularly to check in. She helped them if they had questions about their coverage, explained how to recognize the warning signs that could signal a worsening condition and emphasized the importance of follow-up appointments and the value of using a personal health record to track medical information.
 
Amy and the other case managers on our team help patients and their families focus on what should be their top priority: recovery. That gives patients and their family peace of mind.
 
Case managers are increasingly becoming an integral part of a patient’s health-care team, and you’ll likely see more of them as our health-care system emphasizes coordinated care, improved patient health and satisfaction, and lower costs.

Doctors are hiring them to coordinate care for their patients in organizations such as Think Whole Person Healthcare in Omaha and Southeast Rural Physicians Alliance. The goal is to keep patients on their medications and out of the hospital, which leads to lower health-care costs.

As for Amy’s patient, she recovered well and didn’t have any related readmissions to the hospital, thanks to her doctors, nurses, other caregivers and Amy.

Written by Susan Beaton, senior director of nurse care management and clinical policy

HEALTH INSURANCE TERMS


COINSURANCE

The percentage of the bill you pay after your deductible has been met.

COPAY

A fixed amount you pay when you get a covered health service.

Tiered benefit plan

A health care plan featuring multiple levels of benefits based on the network status of a particular provider. 

DEDUCTIBLE

The annual amount you pay for covered health services before your insurance begins to pay.

emergency care services

Any covered services received in a hospital emergency room setting.

SUBSTANCE ABUSE DISORDER SERVICES

Includes behavioral health treatment, counseling, and psychotherapy


in-network provider

A provider contracted by your insurance company to accept an agreed upon payment for covered services. 

OUT-OF-network provider

A term for providers that aren’t contracting with your insurance company. (Your out-of-pocket costs will tend to be more expensive if you go to an out-of-network provider.)

out-of-pocket

Your expenses for medical care that aren’t reimbursed by insurance, including deductibles, coinsurance and co-payments.

penalty

If you can afford health insurance, but choose not to buy it, you must have a health coverage exemption or pay a tax penalty on your federal income tax return.

premium

The amount you pay to your health insurance company each month. 


Preventive services

Health care services that focus on the prevention of disease and health maintenance.

rehab SERVICES

Services and devices to help you recover if you are injured or have surgery. This includes physical, occupational and speech therapy.

special enrollment period

The time after the Open Enrollment Period when you can still purchase health insurance only if you have a qualifying life event (losing other health coverage, having a baby, getting married, moving).

specialist

A physician who has a majority of his or her practice in fields other than internal or general medicine, obstetrics/gynecology, pediatrics or family practice.