Insurance Case Manager?

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JudyK89
Veteran Member


Date Joined Dec 2006
Total Posts : 1986
   Posted 12/17/2007 1:41 PM (GMT -7)   
Does anyone use one?  I had a call last week from a nurse that says she's a case manager from my insurance company.  She didn't say why she was calling, but I guess that's obvious.  I called her back but haven't reached her yet.
 
Does anyone know if I have to accept a case manager?  The reason I ask is because I've had this disease for so many years, I hate to have someone who knows less about it than I do calling the shots (it's bad enough that some of my doctors have to be educated ;0). The idea that this nurse is being paid by my insurance makes her suspect from the get go, especially as far as maybe getting the tests I may need if they're expensive? 
 
I don't know, it may be a good thing as my insurance can take a long time to approve referrals and hopefully this would speed things up, but I'm not sure how much power they have. 
 
Then I'm wondering what happens if we don't see eye to eye, or if I plain don't like her, or she doesn't like me? 
 
Any info would be appreciated.


Judy
Crohn's Disease   
 
 
 

Post Edited (JudyK89) : 12/17/2007 1:45:26 PM (GMT-7)


Nanners
Elite Member


Date Joined Apr 2005
Total Posts : 14995
   Posted 12/17/2007 2:00 PM (GMT -7)   
That would make me quite suspicious too. I have had Crohns 32 years and the same insurance for over 25 years. Someone calling me like that would get my radar working overtime. Will be curious what she wants. DO keep us posted on that one.
Been living with Crohn's Disease for 32 years.  Currently on Asacol, Prilosec 60 mg, Estrace, Prinivil, Diltiazem, Percoset prn for pain and Calcium.  Resections in 2002 and 2005.  Recently diagnosed with Fibromyalgia and doing tests to see if I have Inflammatory Arthritis or AS.


dragonfly137927
Veteran Member


Date Joined Sep 2006
Total Posts : 2527
   Posted 12/17/2007 2:17 PM (GMT -7)   
I do have one of these case managers. She was the one that called me 2 months after this insurance was my primary...after I lost my better insurance thru my job I had at the time...and told me that this insuracne doesnt cover ostomy supplies then tells me of a place that is 40% off. This was at the point when my reversal was set up and I had plentay at home to get me to the surgery. I was pretty ticked at her back then. I had a visiting nurse at the time who was changing the wound vac dressing. That nurse continued to come after the vac was gone since I still had the abscess drain in. She started giving my home care nurse the 3rd degree about why she had to be at my house. I was so upset at that point from the case manager nurse since she was throwing all of this at me when I should have been told the info she was giving me when my husband told his work that this would now be my primary insurance. I had never had one of these before but was assigned one after my hospital stay.

They are so on the ball there that I got a call in November after my first stay they kept asking for my husband who was at work and were not telling me what it was about. Well the info she was given was that it was my husband in the hospital. She has helped me more recently though. She kept calling and helping my fight with Medco for the authorization of my humira. My dose was doubled from the traditional maintanence dose to help my fistula. Since the whole issue was pending and ammended and denied again and all those issues they were not allowing me to even get my old dosage which I was due for. I had also told her about the issue with the person inputting the CD starter pack in as a 3 month supply and they were giving me issues saying that even tho they messed up they needed authorization from my doc to fix it. Screwball morons ...sry I HATE medco. I get the meds at my local pharmacy I dont mail away for any meds since I never know if doses will change or if I will not be on it long etc.

I still think she has issues with me but I have so many bills they didnt pay for cuz they also didnt tell me til 2 months later that I needed a letter of termination of my old health insurance so that they would be my primary and only health insurance. I have dealt with CS there and they kept saying ok dont tell me any more bills dates, type of appt etc they said we will just go back and all will be fixed in 1 month. It wasnt fixed not 1 part of it....My husband went on a conference call with my case manager nurse and a CS person for my health insurance. I felt maybe if my husband got on the phone...he is the holder of the insurance...plus the case manager that maybe some stuff would get finished. After my husband went thru all of it with her, she did tell him to stop at one point but didnt give him the run around as the CS did to me I also had gotten hung up on b4. Then when they were caught up with apps he went thru then he continues with more of the bills...Afterwards I spoke with her and informed her of what occurred with me when I spoke with someone and I knew the date so the person I spoke with was documented in the computer.

It was a pain in the begining but she has helped a lot especially with my Humira
Dx with Crohn's 1987, symptoms as early as 1984.
Temp iliostomy February 2007, reversed June 2007, Ovarian cysts, migraines, allergies (incl food allergies) , oral allergy syndrome (diff than true food allergies), Asthma, Gall Bladder removed 1999, Inguenal hernia 1987
 
 
 


jujub
Forum Moderator


Date Joined Mar 2003
Total Posts : 10391
   Posted 12/17/2007 3:11 PM (GMT -7)   
A case manager from my insurance company calls me about once a year. She asks me if I've had this and that, and I tell her what's new and why this and that aren't such good ideas and then she leaves me alone for another year. Some years I'm busy and never get around to returning the call, but usually I do. I figure she's trying to earn a living too, and her job depends on talking to a certain number of subscribers, probably. So I give her the fifteen minutes and she goes away and we're both happy.

Judy
 
Moderate to severe left-sided UC (21 cm) diagnosed 2001.
Intolerant to Asacol and rectal mesalamine preparations.
On Prednisone then Entocort 2001-2006 with only short periods off. 
Current meds are Colazal, Azathioprine and Remicade.
In remission since April, 2006. Remicade has been my wonder drug.
 


crohnie42
Regular Member


Date Joined Dec 2006
Total Posts : 371
   Posted 12/17/2007 9:38 PM (GMT -7)   
they are only trying to help
Michele
~~~~~~~~~~~~~~~~~
 
Female Dx'ed with Crohns Disease in 1992
Been on every med for crohns that exists
Several Fistula surgeries
Dx'ed with Colon Rectal Cancer March 2007
Dx'ed with Stage 2 Vulvar VIN
On Chemo and Radiation for 6 weeks
Using Humira with excellent results
IN REMISSION~~~!!!!


JudyK89
Veteran Member


Date Joined Dec 2006
Total Posts : 1986
   Posted 12/17/2007 9:54 PM (GMT -7)   
I hope you're right ;0) I'm not sure what to expect. I've only heard of case managers for certain hospitals or clinics, not for insurance, I guess I'll find out tomorrow when she calls.
Judy
Crohn's Disease   
 
 
 


Zanne
Veteran Member


Date Joined Apr 2005
Total Posts : 3763
   Posted 12/18/2007 6:44 AM (GMT -7)   
My insurance had one calling me last year all the time when I was having repeated hospital admissions. She really didn't know anything about CD or my meds. I kept telling her there really wasn't any info that she could give me that I didn't already have. Finally after several very long phone calls, most during the dinner hour I might add, she agreed that she really wouldn't have much to offer me. However, when I was trying to get transfered out of my local hospital into the bigger hospital in the city so I could get a test done quicker (I was already inpatient, and as an outpatient at the larger hospital I was going to have to wait 2 months), I was able to call her and have her try to help speed the process up. I also see the cheif of GI at that hospital and was calling his office. So in the long run, I'm not sure who was really the one who got me transfered, but I'm glad I didn't totally burn my bridges.

Of course a few months later I got sort of a nasty letter saying I was being dropped from the program because I didn't return this woman's calls. I have caller ID on both my home and cell phones. She had never called me. NOT once. So I think she just didn't want to deal with someone she knew she couldn't help.
Suzanne

CD 19 years offically, 29 unofficially. 3 resections '93, '95 '97
Symptoms constantly but all tests show only minor ulcerations. Currently having multiple episodes of gastritis with no known cause.


Prednisone, 6MP,Prevacid, B12 shots, Bentyl, Xifaxan.....


JudyK89
Veteran Member


Date Joined Dec 2006
Total Posts : 1986
   Posted 12/18/2007 7:08 AM (GMT -7)   
crohnie42 said...
they are only trying to help

Have you used one, or do you know one?  I'm really curious, not sure how they can help me.
Judy
Crohn's Disease   
 
 
 


HabsHockeyFan
Veteran Member


Date Joined Jan 2006
Total Posts : 3130
   Posted 12/18/2007 7:16 AM (GMT -7)   
Judy...I work for the insurance industry. Some RN case managers can be fantastic and others are not so good. It's the same as everything lese in this world. Sometimes it is beneficial to have one involved because they can be your advocate in getting care approved (usually because it is more cost effective for the health plan though).

You can work with one as much as you chose or chose not to have a manager at all. I chose not to have one--I have concerns (real or perceived???) that any more knowledge of my disease may be reflected to my job. I also had some negative experiences with my carrier and the nurses that I have called.

I have worked with RN case managers that helped their patients find local care when needed, less expensive alternatives for DMe etc. You may have a case manager assigned when you are admitted so they can follow your hospital stay. They will often help to get you discharged or get additional days approved.

It all depends on your carriers parameters for the managers and the person you get. If you decide to use the assistance, you can always ask for a new manager or decide to cancel your participation. You may want to try it to have another outlet for info and work from there.
Dx'd '90 (emergency rupture), symptoms ignored long before that, '03 fistulas and bad flagyl reactions, B12 weekly, Pentasa [until I surrender to the bigger meds]
I'm riding on the escalator of life....


JudyK89
Veteran Member


Date Joined Dec 2006
Total Posts : 1986
   Posted 12/18/2007 7:29 AM (GMT -7)   
Thanks Habs,

I'll talk to her and try to figure out how much she knows about this disease and the other issues I'm having. I'll wait and see what she says and/or offers.
Judy
Crohn's Disease   
 
 
 


FitzyK23
Veteran Member


Date Joined May 2005
Total Posts : 4219
   Posted 12/18/2007 8:20 AM (GMT -7)   
I have not been offered a nurse case manager but this is what I gathered from reading my policy info: once someone is diagnosed with chronic illness it is more beneficial (cost wise and compassion wise) for that person to be treated properly from the get go then to not be treated and let it get out of control. So, often, a nurse case manager will be assigned to make sure you understand what you have and how to properly follow your doctors directions. I just get letters in the mail when I am do for a refill. It just says something like "we are reminding you that it is very important to take your medication as directed, please refill soon..." I could see this person being used in your benefit if your doctor suggests something not usually approved and your nurse manager can say "this is necessary to manage her disease and will cost you less in the long run." However, I could see it hurting if you disagree with something your doc recommends and you get labeled as a "non-compliant" patient.

Habs- I understand you don't want your career to be placed in jeopardy. Do you work for the same company that insures you? In regular insurance/business contracts it is highly ILLEGAL for them to mention any of your confidential health information to your employer. Even if you work for that company I would think it would violate HIPPA regulations. I guess it would be awkward if you all shared claimant information as part of your employment and you just happened to be one of those claimants. . .
26 Year old married female.  Diagnosed w/ CD 3 years ago, IBS for over 10 years before that, which was probably the CD.  Currently on Pentasa 4 pills/4x day, hysociamine prn, nexium, and ortho evra.  Good times!!!
 
 


dragonfly137927
Veteran Member


Date Joined Sep 2006
Total Posts : 2527
   Posted 12/18/2007 10:35 AM (GMT -7)   
I have to say as stqated above at the begining I absolutely hated her...didnt let on about that and to be honest I cannot be totally sure it is the same woman I dealt with back in the springtime as I did after these more recent admissions especially since she had info that it was my husband that was admitted not I so someone there screws up the work at united a lot.

She is who I call now whenever I have issues with my Humira it is Medco who screws it up in their computer system and no matter what my doc or my pharmacy does...dunno why medco is who approved humira since I dont get any of my meds mail order I pick them up even the humira at my local CVS. She is the only one who has been able to get me my meds when I needed them while the new dose was being denied and they were told at my GIs office that I was unable to even get my old dose even tho I needed it that night when the case manager nurse was able to get medco to at least allow the old dose to go thru in about 30 minutes what we had tried in the past cuz of their error inputting the CD starter pack we would take a week to try and get and then me on the phone with medco supervisors for 70 minutes to finally fix and told ok there will be no prob next month...what a lie that was! I was amazed what my GIs office was unable to do that this woman was able to do in minutes took them longer to fill the darn script than it was for the CM to get it approved for the old dosage at least
Dx with Crohn's 1987, symptoms as early as 1984.
Temp iliostomy February 2007, reversed June 2007, Ovarian cysts, migraines, allergies (incl food allergies) , oral allergy syndrome (diff than true food allergies), Asthma, Gall Bladder removed 1999, Inguenal hernia 1987
 
 
 


vadreamer1
Regular Member


Date Joined Aug 2006
Total Posts : 196
   Posted 12/18/2007 7:33 PM (GMT -7)   
My insurance company tried to get me to sign up for that. I told them I had enough people weighing in on my care, and adding someone else to the mix was too much in my book.

HabsHockeyFan
Veteran Member


Date Joined Jan 2006
Total Posts : 3130
   Posted 12/19/2007 6:33 AM (GMT -7)   
Fitzy...yup know all about the HIPPA laws in my business. I don't think thye share info, I just think that my company has already done some things that pry into our healthcare (some things they have done to promote getting a discount off premium were tracked within my company and not the carrier). I know I am just being paranoid.
My big issue is that my carrier touts a nurse line...but if you call you always get a computerized "fake" nurse and I could never get a straight answer when I called with questions. Then, when I just looked into costs of imuran and humira I got a call all of a sudden from a live human being. When I explained that I had a very proactive GI and GP and that I did not need assistance, they were pushy.
So...I have refused a case manager for now. i will still consider one if I do go to the bigger meds. Like others have said above, they can be good advocates when dealing with Medco.
Dx'd '90 (emergency rupture), symptoms ignored long before that, '03 fistulas and bad flagyl reactions, B12 weekly, Pentasa [until I surrender to the bigger meds]
I'm riding on the escalator of life....

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