I don’t want to know what company you deal with/work for, I just have one question that you might be able to answer for me. Also, people who have dealt with extensive medical treatment might know this.
If my husband is having surgery followed by a year of Interferon, shouldn’t his health insurance company have a nurse case manager assigned to him? Someone who we can ask for by name when we call with questions?
Yeah, I know the answer to the question but this isn’t a perfect world. Nothing seems to be going right at the moment so I need to know if there is one actual person at his insurance company who cares about him.
Have you read your policy documents? Have you contacted your insurance company?
What may be common sense to you may not be in your policy. It may not be how your carrier does business.
Check to see if your state (in the US) has an insurance ombudsman. Does your Member of Congress support health care? If so, contact them for assistance (hey, it’s a long shot but worth a try).
Why? I’ve had assorted surgeries, and I currently take a drug that the insurance company pays $3000/month for. I’ve never (to my knowledge) had a nurse case manager assigned to me.
Assigning a case manager isn’t really standard practice as far as I know, most insurance companies will have a sort of call center with health care workers that you can call with questions. But I would expect that questions related specifically to your husband’s treatment should be directed at the providers themselves, not providers who work for your insurance company, unless the question is related to coverage for services rendered.
Thanks for the input. I was probably in Pollyanna mode when I wrote the original post. A few years ago I was a nurse case manager for workers’ comp clients, many of whom had difficult cases with multiple doctors and vendors to deal with. But I don’t know how the big companies deal with things today. His case is not what I would call catastrophic (yet) but it has many facets of care that need co-ordination. I was just kind of hoping that there would be an individual that I could know by name and be able to speak with him/her when I had a question. So far, dealing with the MD offices has been quite difficult (multiplied by 5, which is the number of MDs involved). I guess I wanted someone to help me through the maze. My husband insists on doing the calling, even though I am a nurse and “might” know which questions to ask. Perhaps he’ll let me take the reigns soon. Surgery scheduled for the 29th. Fingers crossed…
Why not call your insurance company and ask them about it? Explain the situation and ask if they will assign someone or have the ability to assign someone to assist you with everything. Every plan is different for every person and even the same plan held by two different people at two different companies may have different benefits.
It sounds like you may have two different people you are looking for though, one to answer your insurance questions and one to answer your medical questions. If that is the case you can also ask your insurance company if they cover a nurse case manager and ask his doctor if they will assign a nurse case manager for the situation.
Been lurking on this site a bit - registered just so I could try to help with this one.
FWIW - been working for a major health ins co now for over 15 years.
It’s been my experience that most of the time it’s the diagnosis that triggers case management and not the treatment. If the interferon is being used to treat MS, I would expect it to trigger case management. Other uses for interferon, maybe not.
I can also be a combination of a diagnosis and a certain procedure on a claim that will do it. Meaning the diagnosis alone might not be enough.
These triggers are built into the claims system so that when a triggering claim comes in, the system kicks it over to case management for a look. And then upon human intervention, it could be that they decided the case didn’t warrant management.
Keep in mind too that the primary purpose of case management is to save money and not necessarily to help you with navigating your care. What may seem to you like a complex set of circumstances may be a standard form of treatment where there is little or no room to coordinate care in order to save money.
YMMV as there are a ton of variables. Not all ins cos. operate in the same way. There are all sorts of different state laws that could come into play depending on where you live, if the coverage is through an employer, how large the employer is, individual coverage, medicaid, etc.