Topic: Case Management Programs- are they ok?

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Posted on: Nov 10, 2010 06:38PM

Posted on: Nov 10, 2010 06:38PM

sunshines wrote:

I have gotten several calls from our group insurance wanting us to join this "program" in which I am assigned a nurse to help with any health questions, community referrals, etc. It is a free service, through the insurance co (nurses employed by ins co). I have received several calls, while it sounds very nice, I hesitate because I afraid if I said something to the nurse that works for my insurance company, it may come back to haunt me...you know what I mean Pre excisting down the road, I don;t know- it just worries me.  Anyone have any input on this?

Dx 9/3/2010, IDC, 1cm, Stage IB, Grade 1, 0/5 nodes, ER+/PR+, HER2-
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Nov 11, 2010 06:51AM - edited Aug 20, 2013 03:09AM by OneBadBoob

Back in 2007, I was having horrible problems getting my insurer, Healthnet, to cover much of anything, approving the pre-surgical breast MRI, and was being tossed between one "flunkie" and another, no one knew what they were doing.

I think it was someone here on the board who recommended that I demand a Case Manager from Healthnet, which I did.

She was wonderful and really went to bat for me on approvals for Zofran during chemo--originally they only approved 6 pills per month--(she was the one who faxed the form to me that the onc had to fill out in order to have approval for 30 pills per month--how would I have known it was that easy without her help?)  and on getting the anestesiologist fees paid--can you believe they actually denied payment when I had a single mast and a TRAM reconstruction--I said what do you people think I should have done--had whisky and bit a bullet?

She was also instrumental in helping to get scans and MRI's approved, and extended visits to the LE therapist for my lymphedema.

There are some little "tricks" as to how doctors have to write up requests for Zofran, Zometa, and some scans/MRI's and she pointed me to a website that clearly stated the whos whats and whys of what they will or will not approve, which I directed my onc's nurse to.

p.s.  When they denied my pet/cat scan after chemo because it was scheduled for the same day (they are done in the same machine, for goodness sake!) she told to have my onc fax over a letter that it was medically necessary for me to have them on the same day because of my severe anxiety issues and clastrophobia and I would need to be medicated for these issues, and it would be in my best health interest to have them done on the same day.  Well, lo and behold, they approved it.

Not sure what anyone else's experience was, but I felt that this women had the power to move mountains quickly within the Healthnet system.

I would indeed call up her tomorrow if I was having problems getting any treatments approved.

That was just my experience.

The only thing we ever discussed was the denial of Healthnet for tests and drugs ordered by my onc, so I don't have any worries about ending up in my insurance file, since it was already there anyway.

She sure improved my quality of life during some very difficult times!

Jane - Dance as if no one is watching!! Dx 7/7/2007, IDC, <1cm, Stage I, Grade 1, 0/2 nodes, ER+/PR+, HER2-
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Nov 11, 2010 07:22AM claire_in_seattle wrote:

I have "coordinated care" which means that I got all my treatment from within the same medical system where everyone has online access to all my medical records.  But I am the exception.

Onebadboob's story illustrates why a "case manager" can be very helpful to someone who doesn't have this type of care.  I am amazed in reading these boards at how fragmented (and thus more expensive) so much of the care provided is. 

I had my first really positive experience with insurance case managers a number of years ago when an employee of mine was out with pneumonia and wasn't getting better.  The disability person intervened with her doctor and got him to prescribe a different antibiotic which turned things around immediately.  I realize that the objective of the position is to get employees back to work faster, but in this case, the employee wasn't getting the right care either.

Sunshine.....the medical system I belong to is just now implementing this sort of service (nurse navigator) and I was part of the study a year ago.  I thought it was a wonderful idea.  As for "pre-existing", all of us are there, so I wouldn't worry about that one.  Anyone who does a search on my name will pull up the LIVESTRONG articles.  That is the way it is.  Important now to get the treatment you need, and if this person can help you, I would take that support.

Completed all treatment (AC +T, lumpectomy, radiation and 5 years of AIs - anastrazole). Now celebrating every single day for the wonderful life I have been granted. Dx 8/2009, IDC, Left, 2cm, Stage IIB, Grade 3, 1/21 nodes, ER+/PR-, HER2-
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Nov 11, 2010 05:09PM myrrl wrote:

My situation is naturally simpler than those of you who will have/had chemo, etc., but I have used the nurse case manager for my insurance company. Initially, she just sent me a zillion pamphlets, but recently she handled the back-and-forth for an unpaid bill. A small thing, but it saved me half an hour on the phone and the stress of getting to the right person at my insurance company. 

BRCA1+ (5385insC). BMX w/ L SNB 10/11/10, salpingo-oophorectomy 10/11/10, R breast skin necrosis debridement sx 11/03/10 [staph infection in skin - saved the TE, so far], Exchange 07/08/11. Dx 8/17/2010, DCIS, <1cm, Stage 0, Grade 3, 0/3 nodes, ER-/PR-
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Nov 11, 2010 10:52PM junie wrote:

Sunshines---thanks for starting this thread!   I've been rooting around the boards for a couple days now trying to find a place to post a similar question!!!

Several years ago, my health insurer began providing a 24/7 service that I could call with any health questions I had.   I stuck the magnet with the phone no. on the fridge but never called.   Every so often, I'd get a call asking if I was familiar with this service.  I always politely said,yes--that I had the number posted--thank you......

short story long!!!   A couple months ago I received what seemed like like the millionth call asking if I was familiar with the service offered and I got a little snippy and said I was tired of them calling every week and asking me that......(hubby has identical health coverage; our policies are individual and not dependent on the other and he has NEVER received a call offering him this service...)     well, the lady who called asked could I hold for a second.....and came back to say that she was sorry--they really weren't calling me every week but she knew when the last call had been made to me.    She was extremely pleasant and polite.   She asked if I had a minute to visit with her and asked me a few questions.....she obviously had some kind of access to my recent health history.   I'm currently dealing with a non-bc-related health problem.....(but I'm not sure that chemo/rads didn't contribute to this current issue....)

She has mailed me several informative pamphlets; all her suggestions are prefaced to discuss with my doctor.   The last time she called, she made some suggestions that I might want to talk to my doctor next time I see him.    The other day, I received some related info that she had printed off the internet and mailed to me for info........she knows that I am currently being treated for a severe bronchial infection and will be calling soon just to check up that I'm feeling better.....I'm not being billed for any of her calls/adivce.....yeah, my premiums are going to increase this year but that's a given.....

so........why do I even question this added benefit?   How do I know if this person has any kind of medical background or is she some contracted out person sitting at a computer with access to the same info that I can google and find????   I could ask her, I guess, but how would I know for sure???    I'm struggling with trying to think of the right questions to ask her next time we "visit"   Are my conversations with her confidential?   Does HIPPA apply?   In what specific way is she connected to my particular health care plan?  Does she also represent other health care plans?   What kind of a data base are my responses being entered into?   Just what is her medical background???  Other questions I should ask????

I just don't know what to think--if it truly is a valid service provided by my insurer, in some ways I can see how it could potentially decrease their overall costs by not kicking in for every visit I'd make to the dr if a phone call to this health coach could resolve the problem, or give me additional information for my dr and help him make a determination in one visit instead of two or three.

Guess I grew up in the "Big Brother is Watching You" days, and it is hard to shake my distrust of anything that is outside my comfort zone! 

Any comments/thoughts will be much appreciated.  Sorry for having such a long post.....   

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Nov 12, 2010 10:33AM leaf wrote:

In one situation, I had a good experience, but my friend had a bad experience.

I had prophylactic neck surgery (cervical vertebrae fusion) which I guess usually isn't done prophylactically?  My co-ordinator was beneficial to me and helped with co-ordinating paperwork for me to be off work an extra day when I made appointments in the wrong order.  (Need the doctor approval to go back to work before the Employee Health back to work.) 

On the other hand, Kathy, a friend with stage IV pancreatic cancer, also had a manager. Kathy was a nurse, and worked about 1 week after she was diagnosed.  (It took her about 1.5 months to start any kind of therapy.) Well, I think it was poorly handled all over.  Kathy's boss kept on urging Kathy to go back to work, as did her case manager.  I don't think I'd want to hear that if I was in Kathy's position. If she went back to work, then she'd have to start again from square 1 waiting for Medical benefits after her health benefits ran out. I think her boss maybe wanted Kathy to have some hope of coming back to work, but I don't think she helped Kathy.  Kathy's boss must have known how bad Kathy's prognosis was.

Kathy ended up dying before her benefits ran out. But I don't think its appropriate for a case manager to encourage someone with such a bad prognosis to go back to work if the patient doesn't want that.

Classic LCIS.If knowledge can create problems, it is not through ignorance that we can solve them- Isaac Asimov Dx 12/8/2005, LCIS, ER+/PR- Surgery 1/24/2006 Lumpectomy: Left Hormonal Therapy 7/15/2006 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Nov 12, 2010 10:43AM lago wrote:

I have BCBS of MA and I do have a NP follow me. She is much more responsive than my onc's NP (who I call Nurse Ratched) . Great for questions about SE etc. She has no influence on claims.

You can always cancel but I found this NP to be very helpful. We also have fun because although I'm in Chicago I grew up out in MA. I tease her about her accent all the time… the one I used to have.

DONE!! goo.gl/IoaN6U • Tattoos 2.7.2012 • Nipples 10.6.2011 • Exchange 6.24.2011 • Chemo 1.18. 2011 • BMX 8.31.2010 Dx 7/13/2010, IDC, 5cm, Stage IIB, Grade 3, 0/14 nodes, ER+/PR+, HER2-
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Nov 13, 2010 05:25AM - edited Aug 20, 2013 03:10AM by nmi

Junie, you described it perfectly.  I probably used the wrong title "Case Management". I had a Case Manager help me get approval for my diep breast reconstruction and she was wonderful and worked miracles, when noone else could. She was an angel to me.  I was trying to describe the programs you described.  They call and call.  A few times I had said OK and started answering their questions, after about 10 minutes I get anoided because I'm in the middle of fixing dinner or have to pick up kids and tell her I have to call her back.. then never do.  Why do they need all this info, (in reality, they have it already) .  I have visions of a couple years down the road, requesting services and a recording pop up with a conversation with one of these nurse about something and the insurance co denying, because I did something wrong...

Dx 9/5/2009, IDC, 1cm, Stage IB, Grade 1, 0/5 nodes, ER+/PR+, HER2-
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Nov 13, 2010 10:02AM Susie123 wrote:

I received similar phone calls right after my diagnosis. I was a little standoffish at first but she turned out to be an invaluable source of information. She never pushed any option, she just sent me materials on all options at each step in the process. I knew nothing about BC, but she dealt with it every day and was so much help. After the last step in the process, after reconstruction was complete, we parted ways. I really appreciated having her as a resource.

Dx 12/22/2009, IDC, 1cm, Stage IA, Grade 1, 0/8 nodes, ER+/PR+, HER2-
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Nov 13, 2010 10:22AM YramAL wrote:

I was offered a case manager 2 months after I completed treatment for my breast cancer. It would have been nice to have her while I was going through treatment......

The nurse who called me was as puzzled as I was that I wasn't referred sooner.

Mary 

Mary-Oncotype Score 11 Dx 12/7/2009, IDC, 1cm, Stage IA, Grade 2, 0/4 nodes, ER+/PR+, HER2-
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Nov 14, 2010 08:44AM Mouser wrote:

My husband was offered the "helpful advice" type of assistance by CIGNA, and agreed. They send him pamphlets every so often -- might be useful if he knew nothing about heart disease, but since he is very informed and active in working out his pill regimen (to minimize side effects - he gets them all!) it's a dead waste of pamphlets. Mostly they recommend generic drugs (he's either on them or has had to go off them) and healthier lifestyles (nothing he hasn't done for 30 yrs).

After the bc diagnosis they offered me what was probably the same kindergarten-level 'help', but it might have been something useful, so i called to accept. Only they put me on hold so long i just hung up - *they* solicited my participation, and they haven't got enough people to handle calls? Hardly useful... especially as i was also pretty much done with everything but Femara by then....

On the other hand, my clinic has a person to help cancer patients with bill snafus - that has been useful once or twice.So it's worth checking what's on offer?

mouser - IDC 0.4 cm + DCIS 1 cm, 2007; Stage 1, grade 2, ER+PR-, Her-; lumpectomy, rads, letrozole. More calcs 2008; mastectomy. Quit letrozole 10/09.

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