Case Management Programs- are they ok?

Back in 2007, I was having horrible problems getting my insurer, Healthnet, to cover much of anything, approving the pre-surgical breast MRI, and was being tossed between one "flunkie" and another, no one knew what they were doing.

I think it was someone here on the board who recommended that I demand a Case Manager from Healthnet, which I did.

She was wonderful and really went to bat for me on approvals for Zofran during chemo--originally they only approved 6 pills per month--(she was the one who faxed the form to me that the onc had to fill out in order to have approval for 30 pills per month--how would I have known it was that easy without her help?)  and on getting the anestesiologist fees paid--can you believe they actually denied payment when I had a single mast and a TRAM reconstruction--I said what do you people think I should have done--had whisky and bit a bullet?

She was also instrumental in helping to get scans and MRI's approved, and extended visits to the LE therapist for my lymphedema.

There are some little "tricks" as to how doctors have to write up requests for Zofran, Zometa, and some scans/MRI's and she pointed me to a website that clearly stated the whos whats and whys of what they will or will not approve, which I directed my onc's nurse to.

p.s.  When they denied my pet/cat scan after chemo because it was scheduled for the same day (they are done in the same machine, for goodness sake!) she told to have my onc fax over a letter that it was medically necessary for me to have them on the same day because of my severe anxiety issues and clastrophobia and I would need to be medicated for these issues, and it would be in my best health interest to have them done on the same day.  Well, lo and behold, they approved it.

Not sure what anyone else's experience was, but I felt that this women had the power to move mountains quickly within the Healthnet system.

I would indeed call up her tomorrow if I was having problems getting any treatments approved.

That was just my experience.

The only thing we ever discussed was the denial of Healthnet for tests and drugs ordered by my onc, so I don't have any worries about ending up in my insurance file, since it was already there anyway.

She sure improved my quality of life during some very difficult times!

My situation is naturally simpler than those of you who will have/had chemo, etc., but I have used the nurse case manager for my insurance company. Initially, she just sent me a zillion pamphlets, but recently she handled the back-and-forth for an unpaid bill. A small thing, but it saved me half an hour on the phone and the stress of getting to the right person at my insurance company. 

In one situation, I had a good experience, but my friend had a bad experience.

I had prophylactic neck surgery (cervical vertebrae fusion) which I guess usually isn't done prophylactically?  My co-ordinator was beneficial to me and helped with co-ordinating paperwork for me to be off work an extra day when I made appointments in the wrong order.  (Need the doctor approval to go back to work before the Employee Health back to work.) 

On the other hand, Kathy, a friend with stage IV pancreatic cancer, also had a manager. Kathy was a nurse, and worked about 1 week after she was diagnosed.  (It took her about 1.5 months to start any kind of therapy.) Well, I think it was poorly handled all over.  Kathy's boss kept on urging Kathy to go back to work, as did her case manager.  I don't think I'd want to hear that if I was in Kathy's position. If she went back to work, then she'd have to start again from square 1 waiting for Medical benefits after her health benefits ran out. I think her boss maybe wanted Kathy to have some hope of coming back to work, but I don't think she helped Kathy.  Kathy's boss must have known how bad Kathy's prognosis was.

Kathy ended up dying before her benefits ran out. But I don't think its appropriate for a case manager to encourage someone with such a bad prognosis to go back to work if the patient doesn't want that.

Junie, you described it perfectly.  I probably used the wrong title "Case Management". I had a Case Manager help me get approval for my diep breast reconstruction and she was wonderful and worked miracles, when noone else could. She was an angel to me.  I was trying to describe the programs you described.  They call and call.  A few times I had said OK and started answering their questions, after about 10 minutes I get anoided because I'm in the middle of fixing dinner or have to pick up kids and tell her I have to call her back.. then never do.  Why do they need all this info, (in reality, they have it already) .  I have visions of a couple years down the road, requesting services and a recording pop up with a conversation with one of these nurse about something and the insurance co denying, because I did something wrong...

I was offered a case manager 2 months after I completed treatment for my breast cancer. It would have been nice to have her while I was going through treatment......

The nurse who called me was as puzzled as I was that I wasn't referred sooner.

Mary 

When I called my insurance company in pulling together information about the financial part of joining a clinical trial, I was referred to the cancer case manager service.  The case manager gathered all the relevant information about the trial and made my case before the insurance powers and received the approval.  They fund the "standard of care" of expenses involved in the study. I've completed the usual adjuvant therapy for early stage BC so they agreed to cover the trial's added tests and visits.

The best thing I learned was that the insurance company would pay my travel and lodging expenses if I received this care at a "Center of Excellence".  The nurse calls me after each visit for a chat. 

Her next job is to request approval for continued coverage to the trial expenses in 2011. It's great to have someone who 1. let me know the request must be made each year and 2. does the work for me.  I love dealing with only one knowledgeable person at my insurance company and an experienced RN at that.

She did send me a release to sign giving her extensive authority to contact all my doctors and discuss my situation.  I declined to sign as I am perfectly capable of overseeing my care.

 Because she knows what and how her company makes decisions, I am saved from having to learn the ins and outs of their process.  I believe she has saved me much time and frustration and I know I can terminiate the relationship if needed.

From others comments it seems that there are a range of ways people work with case managers.  

Boo