I was talking to a friend the other day. She was recently diagnosed with lymphoma. She was scared worried and felt she needed to speak to someone about finding a specialist and what she should expect to encounter as she started on her journey.
She told me she decided to call her insurance company and asked to talk to a case manager. She is a case manager herself, so she thought she could depend on another case manager to listen to her and point her in the right direction. Instead, she was told that she was not sick enough to have a case manager. Yes, you read that right – she was told that she was not sick enough to have a case manager. As we talked, I asked myself – why was she told this? I was disappointed and angry that my friend could turned away and told she was not sick enough. My question is: how sick do you need to be to talk to a case manager?
As a nurse case manager/nurse advocate, I tell people to call their insurance company and talk to a case manager when they need help as they know the network and can give the patient choices. I tell people in the hospital to ask for a case manager when they are unsure of what is going on. I don’t expect them to be told, ‘you are not sick enough’. Case managers are resources for people, patients, caregivers, and healthcare team members. They are in place to proactively help people break down barriers and find resources to meet their needs. If they can’t help them – they find someone who can.
Case Managers are supposed to be a resource, someone whom a patient, a member, an injured worker can ask a question, depend on to help find a resource, say they have a problem, and be directed to the one person who can help them. If we are not doing this – what are we in place for?
As a nurse case manager/nurse advocate, I want people to know that they can depend on us when they need a trusted voice to help them. I don’t want to hear ‘you are not sick enough. I know we can’t help everyone – that there are things beyond our control, but we can provide direction to give suggestions for questions a person could ask to clarify things for them. We must provide help – especially when people ask us – Not be told ‘You are not sick enough.’
If you are ever told you are not sick enough to talk to a case manager, please share the Case Management Standards of Practice with the person telling you this. They say; Case managers are recognized experts and vital participants in the care coordination team who empower people to understand and access quality, safe, and efficient health care services.
Here is a link to the Case Management Standards of Practice. https://pmg.joynadmin.org/documents/1054/602c251cef0d263a52749741.pdf
Case managers are in place at every entry point of the broad healthcare system. They should be available to listen and provide direction to those in need. In my mind, everyone should be able to talk to a case manager when they are in need, or why are we in place?
We need to close the disconnect between theory and practice?
Thanks for reading…..have a good week.
Sad, but no surprise. Like you, I would have asked HOW they determine who gets what help and who doesn’t. We need a Healthcare System that supports people being proactive about their health and who tries to gain control right from the very start of their illness. There’s nothing worse than being turned away from the very people who are supposed to be there to help. Thankfully we can turn to those in functional medicine when we run into these kind of roadblocks. But it’s sad that it’s even necessary! Good luck to your friend.
I am just speechless at the heartless response from the Insurance Company. I think that is a time for going up the chain of command. Who supervised the adjuster who said the patient was “not sick enough,” and keep going upwards until you reach the owner of the company and if still no response someone in the Health Care Media would be next. Very sad situation.
Hi Anne–I am not surprised by what happened to your colleague BUT I am disappointed. I think about the people who do not have her level of expertise or ability to self-advocate. I had a similar experience, but it was with my primary care doctor (new). I asked for a referral to a specialist when a test came back with questionable results. My PCP told me a CT scan was not necessary because several journal articles reported the likelihood of significant findings was statistically not likely; I should wait six months. I politely listened to her explanation and then reviewed my health and family history and again insisted upon the test. Finally, she relented but I had to push very hard. I was disappointed that she saw my request as statistically unnecessary, and I told her so. Fortunately, I had my scan and everything turned out OK. I often think about patients who cannot or are unable to question their physicians or insurance company when they need more than “No”
I hope you will discuss these challenges further when you write your book!
That is quite disturbing! I would like to think that the person answering the phone would have to knowledge to provide the correct information and assistance to the caller.
I agree with Maureen and hope you friend calls back and follows the chain of command if she meets with resistance to her request.
I am livid about the Insurance Company’s Case Manager, as you are.
Having done Case Management for Insurance Companies for 35+ years, I would have thought the Case Manager would point your friend in the right direction to prevent her from getting sicker and actually saving the Insurance Company money by early direction of treatment.
I wonder if that particular Case Manager has her/his heart and soul in case management, as most of us do!!
YES, your friend should go up the chain of command and report the response to her when she was actually looking for help to prevent her diagnosis from getting out of hand!
Based on the response your friend received, one must question the requirements this insurance company has to be one of their case managers. Unfortunately, some hosopitals and insurance comapnies hire nurses to fill the role of case manager and provide little to no training.
When working with hospitals, I discovered that staff new to case management were often buddied with a case manager in the department for their orientation and training. This resulted in unstructured learning that was based on one person’s experience and not evidence-based practices.
I am not sure how insurance companies orient their new staff. Advertise job descriptions indicate that the required qualifications include CCMC and/or CPHQ certification, Not sure that happens 100% of the time. Once hired insurance Case managers have specific guidelines and scripts they are required to follow which leaves the individual no leeway to use their critical thinking skills.
I agree the insurance case managers should be able to advise patients and assist to refer them to specialists but I cannot verify this is done by all.
Anne, what a revelation that a professional, especially a Case Manager, turns a patient/client away. Should the insurance guidelines detail she did not formally qualify for a case manager, an empathetic ear, providing resources, and understanding the emotional distress is within the parameters of ‘CARING.’ May case managers across the case management arena experience the sensitivity of patient events.
I worked as a contracted field case manager for a health insurance company. Their computer system would flag claims with certain diagnoses or after a dollar threshold hit for referral to case management. Outside of that if someone called requesting case management it was on a case by case basis but rarely did patients themselves call to request it those usually came from a hospital case manager. I can see how an inexperienced case manager would rely on “the list” and see lymphoma not on it, but not going to a supervisor to ask what services or resources could be provided if the case management program would .not accept that patient is unconscionable. I toobas a case manager called my insurance company requesting case management when a $12k PET scan bill was denied as “investigational”despite having prior authorization. I too was told that I did not qualify but the case manager helped me anyway, guided me to someone in the appeals department. Eventually it was resolved but after a lot of effort and stress I didn’t need.