Advocacy group battles MCOs for patients
76% of toughest cases resolved by case managers
Consumers nationwide are battling their health plans over denial-of-care issues for what they believe to be appropriate and necessary medical services. Managed care case managers often are torn between their patient advocacy role and the realization that a patient’s plan simply doesn’t provide coverage for the proposed treatment plan.
Now, when managed care case managers run into barriers to coverage, their patient advocacy role doesn’t have to end. They can refer their patients to the Patient Advocate Foundation (PAF) in Newport News, VA, a nonprofit group with an amazing track record for resolving conflicts between patients and health plans.
"We do whatever it takes to help the patient. However, our approach has always been to start our communication with the payer by saying that the denial of care or denial of payment after care has been delivered is probably a simple misunderstanding," says Nancy Davenport-Ennis, founder and executive director of PAF.
Denial of care and refusal to pay for care rendered comprise roughly 80% of the more than 29,000 calls PAF received in 1999; other cases have involved job discrimination issues related to a patient’s illness or disability. Of the more than 29,000 cases, 76% were resolved by PAF’s case managers, and the rest were referred to one of the 154 attorneys in the organization’s network.
"We started this organization in 1996. In the four years and several months that we’ve been helping patients, only one case went to court, and that was simply to get an injunction from a judge for a patient to be admitted to the hospital immediately," she says. "I think that payers know that when we contact them on behalf of a patient, we’re not going to go away. We don’t scream, and we’re always fair. However, if we don’t get resolution from the payer, we’re going to go over the payer’s head to the next person to get the patient help."
The first contact patients have when they call the toll-free PAF number is with an intake counselor. The counselor enters the patient’s initial data into the system and then refers the patient to the appropriate staff member. "The intake counselors know from the coding system which staff member is best suited to help the patient resolve their problem," notes Davenport-Ennis.
PAF employs nurse case managers, social workers, psychologists, and attorneys. Staff receive extensive training — including homework each night — during their first two weeks of employment, she says. "We want staff members to be prepared to handle any service area a patient might be confronted with including prescription needs, transportation, food, and clothing."
She attributes PAF’s success to the following three factors:
- Personal dedication. "Everyone in this organization is here to make sure that Americans have access to the medical care they need," she says. "We’ve hired several case managers who came to us from managed care organizations in the past few months. They became tired of telling patients they couldn’t get the care they were requesting and wanted to be part of the solution."
- Consensus and negotiation. She says PAF staff are masters at this. "We’re not here to be offensive to health plans. We work hard to resolve cases on a case-by-case basis."
- Thorough preparation. Before PAF staff contact a patient’s health plan, they go to great pains to make sure "all our ducks are in a row," she says. "We review the health plan document, We ask physicians on our medical board to gather medical efficacy documents about the proposed treatment. We ask our attorneys for every judicial precedent available that this particular treatment is no longer considered experimental. Then we call the plan and offer to send them the documents. Most of the large plans we’ve dealt with in the past know we’ll bury them in paper, if they ask."
Patients who call PAF are never charged for services. "The last thing you need when you’re ill and have huge medical bills piling up is another expense," she says. In addition, PAF has published several patient advocacy publications that also are available to patients at no charge, including a managed care answer guide to help patients solve their insurance problems and a new job discrimination guide to help consumers file their own job discrimination claims.
Case managers can refer patients to PAF’s toll-free number at (800) 532-5274 or the organization’s Web site (www.patientadvocate.org). All of PAF’s publications are available through the site.
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