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By Kathy J Barrows, RN, BSN, CCM

I was a complex case manager, blessed to work with a patient who was diligently managing his diabetes the best he could. Unfortunately, he was a very brittle diabetic whose blood sugar would spike and drop unpredictably, despite his adherence to the diabetic diet and medications the doctor ordered. So, the doctor decided to try a Dexcom monitor that would warn him when he spiked or dropped suddenly, in the hopes that he could avoid hospital admissions. The patient was on his wife’s insurance plan, and he had met his in-network deductible and in-network out of pocket, so the Dexcom would be covered at 100%. Cost was a prohibitive factor for this family.

Then we hit an unexpected bump in the road. His wife’s job changed insurance so that the deductible and out of pocket started over with the new insurance (and it was not calendar year). I had previously seen a fourth-quarter carryover allow an item to be covered at 100%, however that was when the insurance company remained the same. I took a chance and called the new insurance plan to ask if it would be possible to approve a fourth-quarter carryover, covering the Dexcom at 100%. The new insurance did approve a fourth-quarter carryover with 100% coverage! The patient was able to manage his diabetes with the Dexcom, avoid emergency hospital admissions, and dramatically improve his quality of life.

     Tips/Teaching points for our patients:

  • To make the most of their insurance plan, patients need to review their policy every year since it can, and frequently does change.
  • When unsure, suggest the patient call customer service for instructions on accessing their plan and to any ask questions they may have.
  • Instruct them to request a manager when the customer service representative is unable to answer their questions.
  • It can also be necessary for a patient to call human resources at their employer to clarify benefit rules.

Remember, knowledge is power, and one of our primary responsibilities as case managers is to empower our patients to achieve better outcomes.

You need a solid foundation before you can “think outside the box”. CMSA Standards of Professional Case Management Practice provides a common understanding and application of the CM role, process, and expectations. Members receive 50% off this 32hour CE course: https://cmsa.org/sopcmcourse/