Look in your reinsurer for help on difficult cases

 

Saturday, Mar 14,2009, 3:08:28 PM   Click:

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Look to your reinsurer for help on difficult cases

The experts can help provide effective care

If you manage the care of a catastrophically ill or injured patients who need complex care planning, coordination of resources from many sources, and a large allocation of financial resources that could lead the patient to reach its maximum duration of life benefits, it might be useful for you and the patient to know who May share the risk.

Often, this means that the company that provides reinsurance for health care or employer self-insured. Reinsurance companies often use nurses who can help coordinate complex medical cases.

"As a case manager, it is important to note that the plan covers health and when the reinsurance is available as an alternative means of funding and assistance," says Barbara Tomlin, RN, MS, CCM, Assistant Vice President , responsible for medical IOA Re Inc., a reinsurance underwriting whose headquarters is in East Norriton, PA.

Reinsurance is the stop-loss insurance for insurance companies or self-insured employer groups, "says Tomlin. When people experience events with catastrophic health care expenditures, claims May become eligible for funding under the reinsurance, "said Tomlin.

Reinsurance can provide a basis for financial security in an organization by adding another layer of protection against the dollars in care for patients with illnesses or catastrophic injuries.

Once a patient's medical care exceeds a pre-deductible, the reinsurer pays the costs. In some cases, the deductible can be as low as $ 20,000, a threshold easily reached today's health care expenditure, Tomlin stresses.

Since reinsurers assume the financial risk of catastrophic cases, they are likely to experience the best professional or facility in order to exploit the best results for difficult cases the case manager is handling. A reinsurer's medical management department in May have access to national resources and be able to view their clients as providers or facilities have experience and positive results.

"Care-taking decisions and utilization review, however, remain the responsibility of the insurer or HMO," says Tomlin.

Often, reinsurers are willing to get involved in a complex case, even before reinsurance benefits kick in

"Once an insurance company or self-insured employer shall designate a member who needs care during disasters, they can call on us to provide assistance," says Tomlin.

Reinsurers prefer to be informed as soon as possible so they can get a head start on finding the best treatment options for patients, she adds.

"We are often asked to provide assistance before the member needs a transplant, is to anticipate the entry into dialysis, or before a high risk. Proactive management is always more effective, as the evaluation and planning require collaboration for optimal coordination of care, "she said.

In another scenario, when someone has a spinal cord injury, the reinsurer would rather be informed as soon as the patient is admitted to hospital care.

"When we believe occurs from the beginning, we can find a center of excellence, so that when the patient is medically stable, we can arrange transfer to a facility that can provide optimal results in terms of cost effectively" she says.

Reinsurers routinely to cases which are complex and expensive, such as traumatic brain injury, organ transplantation, spinal cord injuries, cancer treatment and dialysis. Some of these cases are more difficult with members who are admitted for surgery, but have multiple comorbidities and who have experienced many complications, "said Tomlin.

"We do not provide hands on case management, but work in an advisory capacity with the insurance case manager to identify the resources that have been used successfully in the past," she says.

For example, if a member needs a transplant, IOA Re is working with four networks that offer specialized care and centers of excellence for transplant surgery.

Recently, the company Tomlin has received notice of a third-party administrator with chronic kidney disease who was facing dialysis or a possible kidney transplant.

The team targeted the IO Re member for individual case management by an expert on kidney disease which was located nearby and in a cost-effectiveness of dialysis facilities. She also assisted in the coordination of pricing options, while more effective in educating members of the dialysis at home if he was aware of all treatment options.

"Where appropriate, the home dialysis clinic and is more financially advantageous for members, because they use less of their health care and the dialyzing daily allowance," says Tomlin.

Because the member may choose to do a transplantation of kidney-pancreas, the case manager has identified centers of excellence for kidney transplant in the member's area.

The reinsurance company has the resources needed to identify the equipment or suppliers can provide the specialized care the member needs, and management of the medical team tries regularly to keep abreast of additional services to clinics and support financial, "she says.

"When a case manager at an insurance company having trouble finding a specialist or a center of excellence, we will identify the best source of care for members," she says.

Often, it is to challenge managers who specialize in a particular area and can give expert advice on the best avenues of treatment for the patient.

In the case of a patient with metastatic cancer, the company can communicate with a management and oncology contract with a case manager who specializes in oncology and the treatment that has studied the standards of care and options Clinical treatment pathways.

"Today, there are many clinical trials and research discoveries that are difficult to follow with the most appropriate types of treatment for cancer. Our case managers and medical advisors to assist us in finding and determine the best treatment of cancer and centers of excellence protocols for members' medical care, "she says.

If an insurer has a member who needs care is complex and is admitted to a medical center in a distant state, IOA Re May employ a case manager to go on the site and meet the treatment team to make recommendations for a specialist consultation or continuing care in an extended care facility or rehabilitation facility.

Tomlin was invited to attend the beginning of the insurer of a member at high risk of pregnancy.

"We know that there are conditions that put pregnant women at risk or diagnostic tests that could confirm that the child has a potential birth defect. We will use a company that can give medical advice to help transport the mother the child as close to term as possible, "she says.

If the fetus is determined to have a congenital defect, such as a heart defect which might require a procedure within a week of birth, the case manager hired by IOA Re could recommend that the child be returned to a center of excellence that can perform the surgery in a timely manner.

Call to the reinsurer expert assistance can help case managers to find the best medical care and the best medical resources to manage the salary of the member so that the best of his maximum benefit from care Health Tomlin stresses.

Most insurance policies on health of $ 1 million to $ 3 million maximum lifetime, "said Tomlin. Case managers need to know what the member of the medical life is to assist members in managing the cost of care to maximize this advantage, she says.

Some providers of dialysis May charge up to $ 500,000 in a year for care of dialysis, making it likely that a person on dialysis may exceed the maximum benefit before becoming eligible for Medicare, says she said.

"To be a good case manager and create the most desirable impact, it is equally important to understand the financial and clinical aspects of managing a complex case," she says.

When a patient's case is complicated, it May be more profitable and get better results if it goes out of town to a center of excellence rather than receiving treatment at local level, she said.

In these cases, insurance case managers can work with their reinsurers to determine the most cost-effective treatment options, identify centers of excellence, and help members to understand the options that make it possible optimize its medical benefits.

"Centers of Excellence have shown that they provide a first-class treatment, and they can often provide care for conditions of contract at a price and with better results than a local can provide," she says .

SOURCE Case Management Advisor