These days as a manager of case management it isn’t often I actually get to practice my individual case management skills. Recently I had an opportunity to change my daily routine and it reconfirmed why I am a case manager.
A few months ago I received a phone call from a senior sales associate asking my help regarding a situation he had just been made aware of. Part of our company’s benefit is an extensive national transplant network and transplant case management services for our members. One of our members had chosen to go to a facility in another state for treatment of his lymphoma by undergoing BMT. His spouse who was eight months pregnant with their first child accompanied him. During his treatment his wife sought out the services of a local OB just in case she needed assistance before returning home to deliver. At the time of the initial appointment she was found to have severely high blood pressure and spontaneously ruptured her membranes. She delivered a normal healthy baby boy.
She returned home with the baby and her spouse continued outpatient treatment. Subsequently, he began experiencing advancing symptoms of his lymphoma and was admitted for treatment, which was eventually determined to be non-transplant-related. I immediately referred him to case management services since this was non-transplant-related. Both the husband and wife were employed by the same company and had elected PPO coverage. The state he was receiving transplant services in had minimal PPO network coverage and both the hospital for non-transplant services and the hospital and providers who delivered the baby were not part of the PPO network.
In reviewing the case, both the member and spouse were informed all services outside of the transplant would need to be provided by PPO facilities in order to utilize the higher level of benefits. To further complicate things the spouse was now being balanced billed by the hospital where she delivered in accordance with state allowable billing practices. The market, the medical director and myself all felt strongly that since we directed this member to this transplant facility the services of the spouse and member not covered under the PPO network should be the responsibility of the plan market office.
I initiated attempts to negotiate with all providers via our contracting department. However, this process continued for several months with no negotiations or resolution. Meanwhile, the family was contacted by a collection agency. In order to preserve their credit history, letters were sent to all parties stating the health plan was actively working to resolve the billing under the benefit plan. Finally, after negotiation attempts failed to produce results the market approved payment in full of all outstanding claims. During this time the member progressed in his treatment, resumed transplant services and was allowed to go home in December. The spouse stated that having someone taking care of the financial issues was such a relief while she was trying to take care of both her husband and a newborn she didn’t know how she would have managed without me. When he returned home and the financial issues were resolved, a case manager again assisted the family only for the wife to call and request another case manager. She stated the case manager was very good, but “she wasn’t like you were. Could I please have someone like you?”
The family had a few months at home with their son before the husband took a sudden turn for the worse, was life-flighted back to the transplant facility for treatment and subsequently died. Because the health plan did the right thing and removed the stress and burden of financial worry, this family was able to spend a few months together at home before the husband expired. In providing peace of mind to this spouse and assisting in their return home, I was again reminded why I am a case manager.
