Look to reinsurer for help with catastrophic cases
Additional resources may be available
If you’re a hospital case manager with a catastrophically ill or injured patient, part of your job as advocate for the patient should be to find out who may be at risk financially for the patient’s care in addition to his or her health insurance coverage, says Joann C. Milne, RN, BSN, CRRN, PHN.
"When hospital case managers are handling a catastrophic case, it’s important for them to ask if there is a reinsurer involved and if the company has medical management that could help them out," adds Milne, assistant vice president of medical management programs with IOA Re, a reinsurance underwriting company with headquarters in Plymouth Meeting, PA. If a reinsurer is involved, you may be able to find additional resources for your patient’s care, she explains.
Milne should know. She was a nurse case manager in a hospital before she took the job with IOA Re. In those days, HMOs had a lot of limitations to rehabilitation and durable medical equipment benefits, often approving only one week of rehabilitation. "Once I found out who the reinsurer was, I would contact that person and let them play devil’s advocate with the health plan," Milne says.
By having the backing of the reinsurer and presenting the patient’s goals and the expected outcomes if the rehabilitation stay was extended, she often was able to get a longer rehabilitation stay for the patient. Case managers in the hospital setting will be well served by increasing their knowledge of insurance resources and reinsurance resources and understanding what reinsurance does, Milne asserts. "Case managers understand the financial aspects as far as benefits go, but to manage cases, they need to see past that."
Now that many hospitals are taking full risk for some clients, hospital case managers should find out if the patient belongs to the hospital risk pool, and if so, is the hospital reinsured and by whom?
In catastrophic cases, hospital case managers should find out who is at risk for the treatment, whether it’s the health plan or the hospital system, and if either party has purchased reinsurance. Start by asking your director of case management who may know if a reinsurer is involved. The chief executive officer, the chief financial officer, and the head of the risk management department should know.
"The important thing is to know to ask the question," Milne adds. Understanding who is financially at risk for care and what resources are available from all at-risk parties helps case managers to be true advocates for their patients and to better coordinate and collaborate, she says.
Developing a good understanding of the insurance component of case management is a way that hospital case managers can distinguish themselves and help their patients at the same time, she adds. If a hospital case manager asks the HMO who the reinsurer is, the health plan is likely to decide to make sure to get the patient’s care going in the right direction before the reinsurer gets involved, Milne adds. "You almost shake a tree when you ask the HMO who their reinsurer is and if there is a contact person you can talk to. They are going to have to think twice about what they’re doing because, ultimately, the reinsurer will support efforts that assure that appropriate resources are being utilized," she says.
A catastrophic case that involves a lot of coordination of resources, a lot of care planning, and a large allocation of financial resources that may or may not cause the patient to reach his or her maximum lifetime benefit should be a flag to the case manager to find out who is at risk.
"Case managers always should make sure they are doing everything they can to get all the appropriate treatment possible for an individual. The reinsurer may have resources that can help above and beyond what the health plan can do," Milne says. The job of the case manager is to make sure they are doing everything they can to get all the appropriate treatment possible for their patients. The reinsurer is one avenue they can explore for resources beyond what the health plan can do, she adds.
"Part of the case manager’s job is to act as an advocate for the patients, making sure they get appropriate treatment, timely coordination of care, and necessary funding to take care of their health care needs. The reinsurer may be a resource to the case manager to help with that advocacy and afford the patient resources above and beyond what the health plan offers," Milne adds.
If youre a hospital case manager with a catastrophically ill or injured patient, part of your job as advocate for the patient should be to find out who may be at risk financially for the patients care in addition to his or her health insurance coverage, says Joann C. Milne, RN, BSN, CRRN, PHN.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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