Look to your reinsurer for help in managing catastrophic cases
CMs should be aware of reinsurance benefits
You’re a case manager for an insurance company, and a spinal cord injury case that needs intensive management and care over a long period of time lands on your desk. You’ve never handled care for a spinal cord injury patient. Where do you turn for help?
- You’re already juggling two difficult cases that require a lot of intervention along with the usual number of routine cases, when a third case that will require a lot of time lands on your desk. What can you do?
- You’re handing a catastrophic case in a distant city but can’t afford to fly in for the team conference. Who will represent your interests in planning care for the patient?
In all three cases, the answer may be the company that reinsures your health plan, says Joann C. Milne, RN, BSN, CRRN, PHN, assistant vice president of medical management programs with IOA Re, a reinsurance underwriting company with headquarters in Plymouth Meeting, PA.
Reinsurers have a lot of experience in dealing with difficult cases. They work nationally with a network of resources across the country and often are willing to help even before the reinsurance benefits kick in, Milne says.
"When a catastrophic case comes along, many more people than just the case manager need to know what’s going on in order to provide the best clinical care with the most effective approach. There may be additional resources that are available through the reinsurer," Milne adds.
For instance, in the case of the patient with the spinal cord injury, the reinsurance company can provide the assistance of a case manager with specific experience in case management of spinal cord injuries to guide the insurance company case manager every step of the way or to actively manage the case.
"Day in and day out, reinsurers are notified of the worst-of-the-worst’ cases nationally," Milne says. "Reinsurers assume financial risk on catastrophic cases. They are likely to know the best professional or facility to tap into to optimize the outcomes for the difficult case the case manager is handling. Most reinsurers have access to national resources and are able to advise their clients as to which providers or facilities have significant experience and positive outcomes. When there is a catastrophic case, we know who would best be able to manage the case and, given the opportunity, we can help coordinate the access to those services."
The reinsurer often has service contracts in place to help from a financial standpoint in using those resources, she adds.
In the case of the three difficult examples, the case manager could consider tapping into the reinsurance resources and give her attention to other cases.
"When an insurance case manager has several heavy cases along with the routine caseload, we can provide resources to help out with the most difficult cases. This additional support enables them to focus on their more routine caseload, those for which the health plan assumes more financial risk. This type of approach develops a true partnership," Milne says.
If you’re managing the care of a catastrophically ill or injured patient in a distant city, the reinsurer may be able to get a case manager in that city to represent your interests at the team conference.
"In most cases, an insurer doesn’t have the resources to fly someone into where the case is being medically managed. Telephone communication can be inadequate with catastrophic cases. If the reinsurer finds value in having an on-site presence, they will make it happen. Having someone on site can improve outcomes both clinically and financially," she says.
Within the last three or four years, reinsurers have seen a greater need to step in and provide medical management before the deductible has been met to prevent the case from going over the deductible, Milne says.
"Often the case management support services are free and are there for the taking, but our clients are too inundated with day-to-day activities to step back and ask for help," she says.
Here’s another example of how the reinsurer can step in: Milne recently handled the case of a Medicare primary patient who was so chronically ill that she was in and out of the hospital to the point of exhausting her Medicare benefit. She wasn’t able to maintain medical stability and stay out of the hospital for 60 consecutive days to renew her Medicare benefit. This meant the self-funded employer group would be responsible for inpatient days unless her Medicare benefits could be renewed.
The third-party administrator called IOA Re to see if it could help. The group would not authorize case management, so the reinsurer stepped in and paid for the cost of a case manager to turn the case around.
"As the reinsurer, this is a case that is going to be potential risk for us, and it appeared as though nobody was minding the shop. Someone needs to find out what’s going on at home, at work, and with her current medical management to work with the patient and her provider to keep her stable and out of the hospital. It’s a case of the reinsurer stepping in and saying, Let us help you,’" Milne says.
Health plans typically work regionally, but reinsurers handle catastrophic care across the country. Some patients may have to go out of their regional network to get the care they need. This is when a reinsurer can help.
"The reinsurer is there to provide financial resources on catastrophic care as outlined in the reinsurance contract, and they have the resources and connections to help their clients best manage the difficult cases," Milne adds.
Reinsurance contracts typically do not specify what the health plan case manager can do, Milne emphasizes.
"The health plan maintains active control over the patient’s case, even though it may ultimately be the reinsurance dollars that are spent," she says.
The reinsurer does not preapprove or pre-deny care. It’s there to help guide a difficult case, provide resources, and provide information to help the client make good decisions. It’s up to the health plan or other reinsure client to approve or deny care, she adds.
"As the risk taker, reinsurance carriers want to make sure appropriate things happen, but in the current market, we can only advise. We can’t and don’t direct care," she says.
However, reinsurers do have the expertise on difficult cases and have put together extensive networks to help best manage catastrophic cases without offending the health plan.
"Reinsurance wants to do what is right. We realize that even though there may be larger expenditures of claims up front, the long-term savings are well worth it. We make sure the appropriate care is done as efficiently and as promptly as possible to minimize the long-term financial aspect of care," Milne says.
The reinsurer can act as a liaison to resources for their clients and often will pay for services with no fee to the client, she adds.
Youre a case manager for an insurance company, and a spinal cord injury case that needs intensive management and care over a long period of time lands on your desk. Youve never handled care for a spinal cord injury patient. Where do you turn for help?You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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