By Jeni Miller
It can be a tense relationship. Healthcare systems and providers — including case managers — have admitted it sometimes feels like insurance is the enemy, and patients have been known to carry that same sentiment.
Matthew Combes, LCSW, LSCSW, CMAC, ACM-SW, director of integrated care for Children’s Mercy Pediatric Care Network in Kansas City, says it does not have to be that way.
“Insurance is not the enemy,” Combes explains. “In the future of healthcare, there is no animosity needed.”
How should case managers and other healthcare professionals work out a healthy connection with insurance companies, and even work to strengthen that connection to help build a more positive view of the relationship among healthcare, insurance, and the patient?
Friend or Foe?
“When I talk to facilities, I often ask them, do they look at insurance as a friend or a foe?” Combes says. “[If they hold] a traditional mindset that insurance is just a hassle and that they’re there to deny everything and create extra paperwork, then they are looking at them as a foe. It doesn’t help provide an opportunity to build that relationship.”
Combes notes there are many “trust issues” between facilities and insurance, especially due to negative experiences like unresponsive representatives or dealing with people who are not local and familiar with the community.
While all of that sometimes is the case, the reality remains that we “need someone from insurance here at the table, and so we have to assume the positive intent that we all have the same goal — the best outcomes for the patient,” Combes says.
Insurance companies also are looking at their bottom line, and they want to avoid readmissions. They do want positive outcomes for their customers — the patients.
“Insurance companies do have some skin in the game to make sure that the patient is getting the right level of care at the right time — and hopefully it is the best level of care,” Combes notes. “They also don’t want to pay additional claims because of something that should have been done. We both want the same thing: What’s best for the patient [in a way] that won’t negatively impact the bottom line.”
In discussions about the insurance relationship with his counterparts at other hospitals, Combes begins by leading his peers through several questions to shed light on the state of these relationships:
- “How often are you in contact with insurance? Is it only when there is a denial or an appeal? If so, that is reactionary, and not the best approach for working to address issues. We want to avoid only waiting until there is a disagreement to discuss the patient.”
- “What does the interaction with insurance look like? Is it positive? Is it just a quick email? Or does it look like getting a denial letter and scheduling a peer-to-peer [meeting]? Does the interaction look more like an opportunity for discussion? If a patient is really complex, we are going to need to do everything we can for them. We need to get them help in the community, so we have to work with payers to determine what we can do to help keep them from coming back to the hospital.”
- “Who is interacting with whom? Is it utilization management (UM) or case managers? Are we discussing with our counterparts at the health plan and inviting health insurance to the table when we have complex patients? We need to talk with them about how to keep the patient safe in the community, create a safe discharge plan, and invite insurance to the table to discuss what we all can do for this patient.”
What Is the Point?
While there are many benefits for strengthening the insurance relationship, among the most tangible are shorter admissions, faster discharges, and fewer readmissions. “Not only that, but it also makes it more likely that the patient will be able to engage with the network, which helps ensure that the patient is as well-connected in the community as possible,” Combes adds.
Those benefits alone make it worthwhile to speak often with insurance companies and even bring in a payer relations team when needed to discover how to work better together. Combes also suggests case managers speak with insurance on a regular basis — before a problem arises — to make the most of that relationship.
“It’s about being proactive rather than reactive” Combes shares. “If we have a patient who we know is complex and has a lot going on, it’s better for the hospital to engage with insurance early and bring them to the discussion to build a safe and secure discharge plan rather than waiting for a denial later and then working on it.”
Of course, this is the ideal. In the real world, case managers must contend with challenges that get in the way of this best practice. One challenge looms over all the others.
“The elephant in the room here, especially with thin staffing, is time,” Combes says. “This is a big issue when you have a lot of patients and need to get them medically stable and out the door. When simultaneously working with insurance companies, it takes additional time to build and maintain those relationships. While long term it can help for shorter and better discharges, it can be lots of work on the front end.”
With staffing shortages, there is a lot on the minds of those in hospitals and other facilities. The hard work of developing relationships with payers is not always going to result in one-to-one success.
“Sometimes, what the patient absolutely needs may not actually exist, regardless of how well we work with insurance, and then we start to shut down,” Combes says. “Rather than letting that shutdown happen, we need to ask ourselves, ‘What is the best that we can do with what is available to us by community providers?”
Aside from grappling with limited time, another roadblock for case managers is framing negative experiences with insurance and keeping a positive attitude for present and future interactions.
“We are tempted to say, ‘Well, insurance has never been able to help us here, so why bother?’” Combes says. “It can be easy to get really bitter when you have too many of those cases and they happen when a patient is so complex that you can’t give them everything you know that they need. There is no magic wand, and sometimes we have to just do what is best and keep a good attitude.”
Likewise is burnout, which Combes notes is something to which case managers are especially prone because they have a “passion for helping, trying to achieve goals, and helping patients achieve great health outcomes. When case managers are faced with times that are hard, it’s very easy to get burned out.”
Still, working with insurance companies and strengthening those relationships in advance can help beat some of that burnout later and provide a better experience for the case manager, the patient, and the payer.
Working well with insurance companies also means working well with others outside the hospital. Knowing the community and the network and how to navigate it nimbly can bolster the insurance relationship — not to mention the patient relationship.
“Hospital systems moving into the value-based care world know that it is no longer enough to focus on what’s inside of those brick-and-mortar walls,” Combes says. “Most insurance companies have some kind of care coordination program, but something that many hospitals far too often don’t think to do is bring them to the table as another resource for that patient in the community.”
“While keeping in regular contact with the insurance care coordination team, the hospital case manager can look at all community pieces, including primary care physicians and specialists and making sure there’s a gap bridged for providers,” Combes explains. “The case manager should not only engage with medical and behavioral health providers in the community, but also the school they look to for the pediatric population. Also, any community-based organizations considering social determinant of health needs.”
What is most important is the community has an opportunity to use its network of providers to wrap around a patient. “That’s what we strive for and exist for — that we in the hospitals can be the advocates for that as we broaden our reach into the community to support the patients here in our community,” Combes explains.
To help make this a reality, Combes recommends case managers — with the support of their hospital systems and leadership — become intentionally involved by serving on community boards, participating in case management associations and conferences, and build valuable relationships outside the hospital.
It can be a tense relationship. Healthcare systems and providers — including case managers — have admitted it sometimes feels like insurance is the enemy, and patients have been known to carry that same sentiment. How should case managers and other healthcare professionals work out a healthy connection with insurance companies, and even work to strengthen that connection to help build a more positive view of the relationship among healthcare, insurance, and the patient?
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