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://cmsapmg.wpenginepowered.com/sopcmcourse/
Great job, Kathy, advocating for your patient!
Thank you for your kind words!! I want to help my patients any way I can so that they can be the best manager of their health!!
Thank you Kathy for making a difference! You are an amazing case manager!
A great example of how we, as case managers advocate for our patients and quality care!
Thanks, Kathy!
Thank you Patricia! I was not sure how the other insurance would respond but if I didn’t try the answer was no but if I tried the answer might be yes…. and in this case, the answer was yes!
Fantastic critical clinical thinking to bridge the gap for this member!
Eileen- thank you for your kind words!! I strive to help my patients any way I can & try to put myself in their shoes: how can I help them to the best of my ability!!
Great example of how “knowledge is power” for both case manager and for patients/families!
Thank you, Mary Beth!! When I have a question, I go to the matter expert whether it be my car, my computer & for our patients, we can help them whether it be a question that they don’t know where to turn & feel stuck, powerless or overwhelmed. I try to give my patients, hugs over the phone & let them know I care…
Thank you for your blog, Kathy! It was very educational and a great contribution to our CMSA chapter!
Thank you Carl for your kind words. I try & put myself in my patient shoes as far as what would be most helpful to me whether it be next steps or information on the health topic.
A great example of working hard to find the best solutions for patients. Keep up the great work!
Thank you Daniel! I love to help my patients any way I can!!
This is a great example of putting the member first through a healthcare transition. I am proud of you Kathy for not stepping out of case management, but for moving forward to ensure the member had continuity of care while moving to the new insurance plan. Bravo!
Thank you Molly for your kind words!! I like to be the bridge or the map to their next steps in their health journey so that they are not stuck, not knowing which way to turn…