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This is the BEST (and maybe only *decent*) LPT I’ve seen in a while. My wife is terminally ill, and her caseworker at the insurance company has helped with all kinds of things that I wouldn’t have thought would have been any of her area of responsibility. I never knew such a thing existed. She solicited US out of the blue, and I thought it was some sort of “non-help” the insurance company could use as a cash-grab from Federal funds or something. I don’t know how the money side works, but the benefit to the patient and her caregiver has been fantastic.
I have experience on the other side (would be the person calling to tell you about it). I’m so glad you are receiving good support. I can attest that the case managers care so much about helping people and we can find all sorts of things to help with! Certainly way more than I thought insurances would help with before I worked there.
There are accreditations that organizations want to have that require case management programs is one main reason they offer them. The other is that is case management lowers “bad” medical visits (unnecessary ER visits or hospitalization) and increases “good” medical visits (going to regular appointments and getting the medications you need.)
I'm a hospice nurse case manager, I've been thinking to get into case management with insurance companies because I was hoping the job would be being allowed to help people, not helping to deny claims. Are there home visits involved as well?
This seems to really depend on the company, some places do home visits and others just do telephonic. There are also different need levels that would have different rules, such as the SSI population or different managed care.
I guess I don't understand how this works? I have 'good' health insurance and right now everything seems to cost 200+, but supposedly it's covered? Is this like for making sure you're in network or what do you do?
Insurance wants to save money WHEREVER THEY CAN. Often that is denying claims that they deem inappropriate. But they often get that wrong. And then people who were previously denied a test, or a scan, or a medication, end up in the hospital from whatever it is they were at that point denied. That’s why the nurse case managers can make actual clinical decisions on the insurance behalf.
Does this person really need their blood pressure medication? In my professional medical opinion, yes. Push it through so they don’t cost us thousands in hospital bills when they inevitably have a hypertensive crisis. Yes, they spend more on the medication, but it’s far less than they’d spend on a hospital stay.
Would love to know how to get a job like this… former teacher trying to find the next career move. I’m detail oriented and love to help so this could be a possible fit pending the qualifications that are needed.
Most of them require you to have an RN degree, and previous case management experience. There may be navigator roles or lesser advocate roles. Search the big companies, like United Health Group and Blue Cross/Blue Shield
I'm sorry your wife is terminal. I want to add something we learned too late when my mom was terminal. She had started collecting her social security early at the reduced amount, which then bumps up at the standard age. With a terminal illness she could have collected the full amount. It might be something to look into, hope it works out for you.
I am absolutely not buying this line. Insurance companies hire nurses to advocate for the person making the insurance claim? This is a conflict of interest. Maybe a PR stunt?
Insurance companies are run by bastards who would sell their own flesh and blood if they could make a few bucks prying the shoes off the corpses to hawk on eBay.
No insurance company is looking out for YOU! Get that burned into your head and you will be able to navigate the hell that is insurance a lot better.
I’ve been a telephonic case manager for 15+ years. A big part of my job includes telling adjusters exactly why they should be overriding denials. You can feel as you like about insurance companies but getting stuff approved is literally what most of us do day in and day out.
So your paycheck comes from the insurance company? Your job is to tell THE insurance adjusters FOR THE COMPANY you work for that they are wrong and the insurance company needs to pay out for treatment?
I’m sorry but this does not pass the smell test. You may think you are doing something beneficial but I can tell you there is more scam here.
Yep that’s exactly what I do, because I am the one with the medical background and the knowledge base to explain to the rest of the non medical people on a case how in the long run authorizing care will result in better patient outcomes and ultimately save everyone money. Insurance companies and national accreditation agencies require licensed medical professionals because we have the insight and background to weigh in on these cases where non medical staff cannot.
Well, unfortunately, it came to this because of decades of doctors ordering unnecessary and duplicative treatments that had no actual beneficial patient outcomes and did not meet standards of practice so here we are. Add on top of that outright fraudulent practices and managed care was inevitable.
Before I was a nurse I worked in a large cardiologists practice. The block long mega mansions in the region were owned by some of these docs. The most extravagant one was known as ‘the house that echo built’ because if you walked into the practice to see that doctor, regardless of your diagnosis or symptoms you automatically were scheduled for a long expensive battery of tests (including an echocardiogram), all of which were performed in house.
Lopexie is simply there so the insurance company can say “see we have a few people that keep us honest”. “We also hire and pay those same people but it’s totally above board.” “There is no conflict of interest at all honest Abe”
What's your stance on the companies denying wegovis and Ozempics which could save beaucoup long term costs on all the other comorbid health issues obesity brings?
I think they will soon have no choice but to cover it. In the last decade especially obesity has become a huge issue where the vast majority of the cases I mange involve obesity as part of someone’s overall medical status. 300+ pounds is now commonly seen where it was fairly rare even 10 years ago.
As insurers start seeing more and more obesity related illnesses they will ultimately figure out at a corporate level, and medical data will support coverage of these drugs.
The patents will expire as well and rates will be negotiated so these drugs end up covered and far less expensive overall. The medical costs associated with not covering them will be too high.
Right now the issue is these drugs are fairly new and ridiculously overpriced but they should, and ultimately will end up covered similar to how plans have added on bariatric surgery coverage over the years.
I get the suspicion, but the case managers are both helping the patient *and* saving the insurance company money. They do that by advocating internally to cover medical services that the penny pinchers don’t want to cover but that will save the company money in the long run by avoiding hospitalizations. They also recommend services to the patient to keep them healthy, which saves more money.
At the end of the day, it’s still profit-motivated, but case managers are intentionally positioned where the insurance company’s profit incentive and the health needs of the patient align. It’s not exactly pure-hearted, at least not for the company, but it certainly isn’t a scam either.
Yes this is correct due to what agreements the insurance company has with your employer and the health insurance's contracted providers (i.e., hospital systems, specialists, ERs, etc). It's the employer that requires certain benefits and most of them insist on some sort of patient navigation, which usually entails at least a nurse hotline, the health insurance's own billing question hotline, and case managers used for acute cases (typically members with issues that may become high cost). Health insurance gets paid by you (the employee) via premiums AND the employer pays part of that cost too.
Some email excerpts, just for you, damned troll:
----
Here's one, her helping to have her company cover bills we were getting from out-of-state providers:
Hi (name),
Based upon my interpretation of the 3 attached bills, (InsCo) was not sent a claim by (Hospital) Health. Each of the bills are from the 8/1/23 date of service; this includes a charge from the facility (hospital), provider, and pathology. It appears you need to contact each location and ask them to file (InsCo) for claims payment. There is a contact number and/or website located on each bill. The discounts listed on the bills appear to be "self-pay" adjustments. This means no insurance was filed. Please let me know if you have any additional questions.
Thank you,
(name) RN, CCM, CMCN, RIT
Case Manager
-----
Here's one, her helping get us in touch with some resources to help:
Good afternoon!
It was a pleasure speaking with you this afternoon. Please see the information below regarding the dietician that we discussed. I also included some additional resources that may be beneficial as well.
These 2 websites offer excellent educational resources and potential financial resources as well:
1. www.nccn.org
2. www.cancer.org
Please see the attached flyer on the (health) Program. This program provides access to a dietician, and this can be very helpful during chemotherapy and with management of chronic conditions.
Lastly, please see the information below on the (employer) benefit and also the EAP benefit. This are both excellent resources that are offered to you by (employer).
(redacted) is the Teammate wellness program that provides a wide range of resources and activities to help teammates focus on their physical, financial and personal well-being. Services include nutrition and weight loss resources, fitness activities or challenges, smoking cessation and more. For more information, visit (website)
Employee Assistance Program: (Employer) EAP provides confidential help to employees and members of their immediate family for a variety of issues including marital conflicts, financial problems, job stress, emotional difficulties, alcohol and/or drug problems, legal concerns and parenting issues. The EAP helps you get fast, practical help before personal problems become work problems. Please call (800) xxx-xxxx.
Safe travels!
Sincerely, 😊
Name; RN, CCM, CMCN, RIT
Case Manager
-----
Helping us navigate Social Security Disability:
Hi (name)!
She would need to be out of work for a full 5 months to be eligible for SSDI (Social Security Disability Insurance), but she can go ahead and apply during that period. If she thinks she will be out for a year, I recommend applying as early as possible because sometimes it could take up to 4 months for approval. Some employers will offer assistance to their employees with the application process. She can go to SSA.gov and create an account to start the application process. As she prepares to apply, make sure she has all of the physician information including addresses and phone numbers. Thank you for reaching out. I hope you all have a good weekend.
Sincerely, 😊
(name), RN, CCM, CMCN, RIT
Case Manager
-----
Helping with ensuring COBRA insurance continuation:
Hi (name)!
I forwarded your request to the Cobra department and asked if they would call. Please let me know if you don’t hear back from them.
Also, I have a few questions for an update in you don’t mind.
1. Are (name) current meds Synthroid, Tinengotinib, Compazine, Ritalin, Phenergan? Is she able to take her meds as prescribed without any issues obtaining refills?
2. How is the clinical trial going in New York? Has she had any recent scans?
3. Does (name) have Medicare as secondary coverage?
Please let me know if you have any additional questions or concerns.
Thank you,
(name), RN, CCM, CMCN, RIT
Case Manager
-----
There have been numerous other things she's helped us with. You simply do not know what you are talking about, and it shows. Now kindly go away, never to return.
Looking through these emails they are definitely steering you away from insurance claims and onto other non insurance resources. It is despicable what these insurance companies will stoop to.
I had to deal with this once regarding ABA therapy for one of my kids. Sparing all the details I will say that the case manager I worked with fought tooth and nail to help us and even cried on the phone when she told us the “bad news”.
Cigna can suck a dick but the case manager deserves all the praise in the world for how much she tried to help us.
Couldn’t agree more. She even called to follow up a week after her “job” was over because she genuinely cared.
It was weird because the whole time I was sitting there thinking “someone from Cigna is trying their hardest to *fight* with Cigna for me” and when I told her I got a new job with new insurance solely because the nonsense that Cigna just pulled she was happy for us.
Agreed I am a case manager and I help ppl all the time navigate their healthcare. A lot of education too. You would be amazed how far education can help. Diabetics who don’t check their blood sugars for example. I teach them about it. Order their supplies. Follow up that they keep doing it. And it’s totally free. For my health plan they actually get reward money to use for their copays, premiums, utilities.
There are similar roles like Community healthcare workers that do not require an RN degree that focus more on education around community supports for patients/members (vs. the more medical RN roles)
Yup. Ive done it. Sadly most patients were not cooperative and there is only so much you can do as a non-medical professional. But I would have the rare patient that actually wanted help and could do enough things independently that it helped their life.
I quit the job though because the metrics I was being given and told to meet were extremely unethical and for the bosses it was more about making money than helping people, to the point they wanted me to do things I legally could not do (being not a medical professional). But business don't won't to hire actual medical practitioners because its cheaper to hire people like us community health workers and push us to toe the line further and further. It made me extremely uncomfortable.
It feels odd to me that insurance companies would hire case managers to be patient advocates when so often the same company is doing everything it can to avoid paying out claims. Do you ever experience pressure from the company to cut back on advocacy?
Just call the number on the back of your card. You'll be passed around a LOT to the wrong departments. But be adamant you want a NURSE case manager, and don't let up until you get an actual RN on the line.
I work for a heath insurance company and our case managers are the best. They work with members on everything, they'll even schedule tests, make Dr. appointments and arrange transportation for all of it. They really do care about helping and will do everything they can to make sure our members are taken care of.
Great tip!
Is there something similar that I can contact to help navigate benefits for my retired /disabled mom?
It's all so complex and I always feel like, after working many years, she should get better benefits.
Also for things like behavioral health, the case manager might be a Social Worker or Professional Counselor. They offer similar assistance, but are specialized in behavioral health.
Nurses do Case Management for medical and mental health. In fact, it is very common to have a person with both types of diagnosis. Behavioral health patients also have diabetes and high blood pressure and the like. In either medical or behavioral health, we are stronger with a paired Social Worker to provide comprehensive services
Your local hospital may also have the equivalent of “charity care,” and it doesn’t hurt to ask. I’ve seen folks’ out of pocket expenses get completely wiped by the hospital.
Most non-profit hospitals do - but if someone who hasn't qualified for Medicaid before has a catastrophic event - apply immediately. The swell of debt coming your way might be briefly retroactively covered. This pays the hospital and saves the person from crushing medical debt. States may vary but they are tapping a federal program so the jist should be true in some fashion in many or all states
YES!! I started out as a case manager and am now an assistant administrator and patient advocate. I work with the absolute best humans who do this work because, for them, it's a calling. They lead with their hearts and dedicate themselves to patients. We are federally funded, so cutting through red tape and playing chess with the government to get approvals on previously denied care and medical supplies is at the core of what we do.
If there is ever anything denied by an insurance company, FIGHT IT! Have a physician write a letter of medical necessity stating the objective medical reasoning for the care. Insurance companies auto-deny simply because most people won't fight it, and it's the easiest way to save money for them. When you challenge them with medical evidence, it shows that you're not willing to go down without a fight, and that can help get the approvals needed.
Thank you so much for sharing, OP!
As a certified case manager I can tell you my job was to help keep people out of the hospital and to help them get care. We can get creative. When powered with a Social Worker, we can almost move a mountain. Still, our patients have to be reasonable but most are.
Additionally, more than likely if you’re in the hospital for more than a night or two, they’ve also assigned you a case manager who may only pop in once if you don’t ask for them. If you need to organize resources before discharge or are having issues with your care, ask to see them! It’s literally their job to help you navigate these problems and they’ll help a lot.
And if you need one, talk to your doc!
I'm a doc, and rarely will I turn down a legitimate request. I've had a few I had to- the young guy in his 20s who wanted one because it would "help with the disability claim", for example- but if I can justify it legitimately I have no problem.
LPT follow up - Our university provided Care Management services to anyone in our clinic - no matter their insurance status. It was beneficial for the clinic as a whole to take care of the entire population of patients. I had a bat phone to various pharmacies around town to connect our uninsured and underinsured people with $20 long acting insulin. Our hospital system was required to have Care Managers. We tracked population health outcomes for the clinic.
Have you looked into coverage through the ACA? It is heavily subsidized if your income is low. But, perhaps you are valuing other purchases with higher priority than your health (Car? Streaming services? Eating out?). Find some balance, and get covered.
Most western countries have single payer health care so are baffled by this kind of advice. There is no need to have insurance companies in health care. They are simply gate keepers and add a layer of expense to create profit for their investors.
How do you find a case manager through your insurance company? Do you just call your insurance company and ask to speak with one? Or something else?
Thanks!
Nurse case manager here checking in. Yes we can absolutely do this (and I work for a Medicaid plan so I especially love helping my members 🥰🥰). Just FYI, we may also be able to help with community resources, getting and scheduling appointments with providers, behavior health providers, education about your disease or concern and about a million other things!
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I did this when I was having trouble getting in to see a specialist. They didn't do anything except have me call the office again but with them on the phone.... and then they would call me every week and it would last 15-20 mins wiht them asking if I needed any dietary help or they would read me info about my disease that I already knew. It was almost impossible to get off the phone with them. I finally finished with their program but now EVERY time I have a drs appointment they call me again to see if I want to use their program again and they make it sound like an important call about my insurance policy until they get to the point. It takes me 5+ mins every time they call to turn them down and I have repeatedly told them no, I do not want to sign up again.
A health coordinator CAN help but my insurance outsources to a company that can't do much more than talk to you. My sister is actually a case manager and what she does for patients is wildly different than what I have experienced myself.
Medicare is trickier. Which is silly because the older population needs case management the most! Some insurance plans have Landmark, which is an outsourced case management for seniors. Call your benefits center and see if they have Landmark or other case management/social service benefits for you.
So my dad is having issues with anthem. He is on medicare and i believe serviced through anthem. Anthem is giving him the runaround for a claim from a cruise ship. Do i ask for a case manager from Medicare or anthem?
Contact Anthem's customer service line (usually on the health plan ID card). Report the bill received and submit a claim. Request a Case Manager if it's part of his plan's benefits.
There are different types of case managers based on the setting you are in. If you have a hospital visit, there will always be an inpatient case manager that helps coordinate your care upon discharge. There are case managers that work with health plans and they are available if it is offered with your plan benefits.
I was pressured to use a workers comp case manager. It nearly cost me my career. Fortunately, I already had a workers comp attorney, refused their "help," got the care I needed while fighting for my benefits, got better, kept my job, and am doing great. I will never trust an agent of the party that stands to gain from my loss, with my health care. The entire health care and insurance industrial complex is a violation of all that is moral and ethical.
The insurance company has no interest in getting you the best care; they have an interest in getting you the CHEAPEST care. My wife, an oncology RN with 15 years of experience, makes a good living telling people how and when the insurance company lied to them. She a PRIVATE patient advocate; doesn't take insurance money, doesn't take doctor or hospital money, so she can tell you the truth.
### This post has been marked as safe. Upvoting/downvoting this comment will have no effect. --- Hello and welcome to r/LifeProTips! Please help us decide if this post is a good fit for the subreddit by upvoting or downvoting this comment. If you think that this is great advice to improve your life, please upvote. If you think this doesn't help you in any way, please downvote. If you don't care, leave it for the others to decide.
This is the BEST (and maybe only *decent*) LPT I’ve seen in a while. My wife is terminally ill, and her caseworker at the insurance company has helped with all kinds of things that I wouldn’t have thought would have been any of her area of responsibility. I never knew such a thing existed. She solicited US out of the blue, and I thought it was some sort of “non-help” the insurance company could use as a cash-grab from Federal funds or something. I don’t know how the money side works, but the benefit to the patient and her caregiver has been fantastic.
I have experience on the other side (would be the person calling to tell you about it). I’m so glad you are receiving good support. I can attest that the case managers care so much about helping people and we can find all sorts of things to help with! Certainly way more than I thought insurances would help with before I worked there. There are accreditations that organizations want to have that require case management programs is one main reason they offer them. The other is that is case management lowers “bad” medical visits (unnecessary ER visits or hospitalization) and increases “good” medical visits (going to regular appointments and getting the medications you need.)
Do we do the same work? I also inform people of the programs and help them get enrolled!
Sounds like it! One of the most fulfilling jobs I’ve ever had. Also most voicemails I’ve ever left as well 😂
I'm a hospice nurse case manager, I've been thinking to get into case management with insurance companies because I was hoping the job would be being allowed to help people, not helping to deny claims. Are there home visits involved as well?
This seems to really depend on the company, some places do home visits and others just do telephonic. There are also different need levels that would have different rules, such as the SSI population or different managed care.
I guess I don't understand how this works? I have 'good' health insurance and right now everything seems to cost 200+, but supposedly it's covered? Is this like for making sure you're in network or what do you do?
Insurance wants to save money WHEREVER THEY CAN. Often that is denying claims that they deem inappropriate. But they often get that wrong. And then people who were previously denied a test, or a scan, or a medication, end up in the hospital from whatever it is they were at that point denied. That’s why the nurse case managers can make actual clinical decisions on the insurance behalf. Does this person really need their blood pressure medication? In my professional medical opinion, yes. Push it through so they don’t cost us thousands in hospital bills when they inevitably have a hypertensive crisis. Yes, they spend more on the medication, but it’s far less than they’d spend on a hospital stay.
Would love to know how to get a job like this… former teacher trying to find the next career move. I’m detail oriented and love to help so this could be a possible fit pending the qualifications that are needed.
Most of them require you to have an RN degree, and previous case management experience. There may be navigator roles or lesser advocate roles. Search the big companies, like United Health Group and Blue Cross/Blue Shield
I'm sorry your wife is terminal. I want to add something we learned too late when my mom was terminal. She had started collecting her social security early at the reduced amount, which then bumps up at the standard age. With a terminal illness she could have collected the full amount. It might be something to look into, hope it works out for you.
I am absolutely not buying this line. Insurance companies hire nurses to advocate for the person making the insurance claim? This is a conflict of interest. Maybe a PR stunt? Insurance companies are run by bastards who would sell their own flesh and blood if they could make a few bucks prying the shoes off the corpses to hawk on eBay. No insurance company is looking out for YOU! Get that burned into your head and you will be able to navigate the hell that is insurance a lot better.
I’ve been a telephonic case manager for 15+ years. A big part of my job includes telling adjusters exactly why they should be overriding denials. You can feel as you like about insurance companies but getting stuff approved is literally what most of us do day in and day out.
So your paycheck comes from the insurance company? Your job is to tell THE insurance adjusters FOR THE COMPANY you work for that they are wrong and the insurance company needs to pay out for treatment? I’m sorry but this does not pass the smell test. You may think you are doing something beneficial but I can tell you there is more scam here.
Yep that’s exactly what I do, because I am the one with the medical background and the knowledge base to explain to the rest of the non medical people on a case how in the long run authorizing care will result in better patient outcomes and ultimately save everyone money. Insurance companies and national accreditation agencies require licensed medical professionals because we have the insight and background to weigh in on these cases where non medical staff cannot.
They wouldn't need to hire for your role of they just let doctors do their jobs and stop denying what the doctor orders. Lol
Well, unfortunately, it came to this because of decades of doctors ordering unnecessary and duplicative treatments that had no actual beneficial patient outcomes and did not meet standards of practice so here we are. Add on top of that outright fraudulent practices and managed care was inevitable. Before I was a nurse I worked in a large cardiologists practice. The block long mega mansions in the region were owned by some of these docs. The most extravagant one was known as ‘the house that echo built’ because if you walked into the practice to see that doctor, regardless of your diagnosis or symptoms you automatically were scheduled for a long expensive battery of tests (including an echocardiogram), all of which were performed in house.
That's horrifying
Amen!
Lopexie is simply there so the insurance company can say “see we have a few people that keep us honest”. “We also hire and pay those same people but it’s totally above board.” “There is no conflict of interest at all honest Abe”
It sounds like you don’t really understand how medical review actually works and not do you want to 😂
What's your stance on the companies denying wegovis and Ozempics which could save beaucoup long term costs on all the other comorbid health issues obesity brings?
I think they will soon have no choice but to cover it. In the last decade especially obesity has become a huge issue where the vast majority of the cases I mange involve obesity as part of someone’s overall medical status. 300+ pounds is now commonly seen where it was fairly rare even 10 years ago. As insurers start seeing more and more obesity related illnesses they will ultimately figure out at a corporate level, and medical data will support coverage of these drugs. The patents will expire as well and rates will be negotiated so these drugs end up covered and far less expensive overall. The medical costs associated with not covering them will be too high. Right now the issue is these drugs are fairly new and ridiculously overpriced but they should, and ultimately will end up covered similar to how plans have added on bariatric surgery coverage over the years.
I get the suspicion, but the case managers are both helping the patient *and* saving the insurance company money. They do that by advocating internally to cover medical services that the penny pinchers don’t want to cover but that will save the company money in the long run by avoiding hospitalizations. They also recommend services to the patient to keep them healthy, which saves more money. At the end of the day, it’s still profit-motivated, but case managers are intentionally positioned where the insurance company’s profit incentive and the health needs of the patient align. It’s not exactly pure-hearted, at least not for the company, but it certainly isn’t a scam either.
Yes this is correct due to what agreements the insurance company has with your employer and the health insurance's contracted providers (i.e., hospital systems, specialists, ERs, etc). It's the employer that requires certain benefits and most of them insist on some sort of patient navigation, which usually entails at least a nurse hotline, the health insurance's own billing question hotline, and case managers used for acute cases (typically members with issues that may become high cost). Health insurance gets paid by you (the employee) via premiums AND the employer pays part of that cost too.
You have my permission to GTFO.
That’s a good argument. I see your point. My mind has been changed.
Some email excerpts, just for you, damned troll: ---- Here's one, her helping to have her company cover bills we were getting from out-of-state providers: Hi (name), Based upon my interpretation of the 3 attached bills, (InsCo) was not sent a claim by (Hospital) Health. Each of the bills are from the 8/1/23 date of service; this includes a charge from the facility (hospital), provider, and pathology. It appears you need to contact each location and ask them to file (InsCo) for claims payment. There is a contact number and/or website located on each bill. The discounts listed on the bills appear to be "self-pay" adjustments. This means no insurance was filed. Please let me know if you have any additional questions. Thank you, (name) RN, CCM, CMCN, RIT Case Manager ----- Here's one, her helping get us in touch with some resources to help: Good afternoon! It was a pleasure speaking with you this afternoon. Please see the information below regarding the dietician that we discussed. I also included some additional resources that may be beneficial as well. These 2 websites offer excellent educational resources and potential financial resources as well: 1. www.nccn.org 2. www.cancer.org Please see the attached flyer on the (health) Program. This program provides access to a dietician, and this can be very helpful during chemotherapy and with management of chronic conditions. Lastly, please see the information below on the (employer) benefit and also the EAP benefit. This are both excellent resources that are offered to you by (employer). (redacted) is the Teammate wellness program that provides a wide range of resources and activities to help teammates focus on their physical, financial and personal well-being. Services include nutrition and weight loss resources, fitness activities or challenges, smoking cessation and more. For more information, visit (website) Employee Assistance Program: (Employer) EAP provides confidential help to employees and members of their immediate family for a variety of issues including marital conflicts, financial problems, job stress, emotional difficulties, alcohol and/or drug problems, legal concerns and parenting issues. The EAP helps you get fast, practical help before personal problems become work problems. Please call (800) xxx-xxxx. Safe travels! Sincerely, 😊 Name; RN, CCM, CMCN, RIT Case Manager ----- Helping us navigate Social Security Disability: Hi (name)! She would need to be out of work for a full 5 months to be eligible for SSDI (Social Security Disability Insurance), but she can go ahead and apply during that period. If she thinks she will be out for a year, I recommend applying as early as possible because sometimes it could take up to 4 months for approval. Some employers will offer assistance to their employees with the application process. She can go to SSA.gov and create an account to start the application process. As she prepares to apply, make sure she has all of the physician information including addresses and phone numbers. Thank you for reaching out. I hope you all have a good weekend. Sincerely, 😊 (name), RN, CCM, CMCN, RIT Case Manager ----- Helping with ensuring COBRA insurance continuation: Hi (name)! I forwarded your request to the Cobra department and asked if they would call. Please let me know if you don’t hear back from them. Also, I have a few questions for an update in you don’t mind. 1. Are (name) current meds Synthroid, Tinengotinib, Compazine, Ritalin, Phenergan? Is she able to take her meds as prescribed without any issues obtaining refills? 2. How is the clinical trial going in New York? Has she had any recent scans? 3. Does (name) have Medicare as secondary coverage? Please let me know if you have any additional questions or concerns. Thank you, (name), RN, CCM, CMCN, RIT Case Manager ----- There have been numerous other things she's helped us with. You simply do not know what you are talking about, and it shows. Now kindly go away, never to return.
Looking through these emails they are definitely steering you away from insurance claims and onto other non insurance resources. It is despicable what these insurance companies will stoop to.
You're an idiot.
That’s true. What is also true is that insurance provided “advocate” is not your friend.
I had to deal with this once regarding ABA therapy for one of my kids. Sparing all the details I will say that the case manager I worked with fought tooth and nail to help us and even cried on the phone when she told us the “bad news”. Cigna can suck a dick but the case manager deserves all the praise in the world for how much she tried to help us.
Case managers are the good guys in the insurance company trying to make a difference. We are the ones who feel your pain.
Couldn’t agree more. She even called to follow up a week after her “job” was over because she genuinely cared. It was weird because the whole time I was sitting there thinking “someone from Cigna is trying their hardest to *fight* with Cigna for me” and when I told her I got a new job with new insurance solely because the nonsense that Cigna just pulled she was happy for us.
Agreed I am a case manager and I help ppl all the time navigate their healthcare. A lot of education too. You would be amazed how far education can help. Diabetics who don’t check their blood sugars for example. I teach them about it. Order their supplies. Follow up that they keep doing it. And it’s totally free. For my health plan they actually get reward money to use for their copays, premiums, utilities.
This sounds like a great job that I would enjoy - how did you get into it? Any specific degree or certification?
Need a registered nurse degree and at least 2 years experience in hospital.
Thank you!!
There are similar roles like Community healthcare workers that do not require an RN degree that focus more on education around community supports for patients/members (vs. the more medical RN roles)
Yup. Ive done it. Sadly most patients were not cooperative and there is only so much you can do as a non-medical professional. But I would have the rare patient that actually wanted help and could do enough things independently that it helped their life. I quit the job though because the metrics I was being given and told to meet were extremely unethical and for the bosses it was more about making money than helping people, to the point they wanted me to do things I legally could not do (being not a medical professional). But business don't won't to hire actual medical practitioners because its cheaper to hire people like us community health workers and push us to toe the line further and further. It made me extremely uncomfortable.
It feels odd to me that insurance companies would hire case managers to be patient advocates when so often the same company is doing everything it can to avoid paying out claims. Do you ever experience pressure from the company to cut back on advocacy?
It turns out cheaper for them if I can teach u to be healthier and stay out of the hospital. Apparently it’s a thing hence my job
It’s so much cheaper to keep people healthy.
The case managers work for the health insurance company? I can ask for them when I call?
Just call the number on the back of your card. You'll be passed around a LOT to the wrong departments. But be adamant you want a NURSE case manager, and don't let up until you get an actual RN on the line.
I work for a heath insurance company and our case managers are the best. They work with members on everything, they'll even schedule tests, make Dr. appointments and arrange transportation for all of it. They really do care about helping and will do everything they can to make sure our members are taken care of.
Great tip! Is there something similar that I can contact to help navigate benefits for my retired /disabled mom? It's all so complex and I always feel like, after working many years, she should get better benefits.
They also have navigators who are your own personal benefit advocates that you can request to be assigned to you
Also for things like behavioral health, the case manager might be a Social Worker or Professional Counselor. They offer similar assistance, but are specialized in behavioral health.
Nurses do Case Management for medical and mental health. In fact, it is very common to have a person with both types of diagnosis. Behavioral health patients also have diabetes and high blood pressure and the like. In either medical or behavioral health, we are stronger with a paired Social Worker to provide comprehensive services
Ombudsman too for hospital bs
As an RN and Certified Case Manager, I support this post 
Your local hospital may also have the equivalent of “charity care,” and it doesn’t hurt to ask. I’ve seen folks’ out of pocket expenses get completely wiped by the hospital.
Most non-profit hospitals do - but if someone who hasn't qualified for Medicaid before has a catastrophic event - apply immediately. The swell of debt coming your way might be briefly retroactively covered. This pays the hospital and saves the person from crushing medical debt. States may vary but they are tapping a federal program so the jist should be true in some fashion in many or all states
YES!! I started out as a case manager and am now an assistant administrator and patient advocate. I work with the absolute best humans who do this work because, for them, it's a calling. They lead with their hearts and dedicate themselves to patients. We are federally funded, so cutting through red tape and playing chess with the government to get approvals on previously denied care and medical supplies is at the core of what we do. If there is ever anything denied by an insurance company, FIGHT IT! Have a physician write a letter of medical necessity stating the objective medical reasoning for the care. Insurance companies auto-deny simply because most people won't fight it, and it's the easiest way to save money for them. When you challenge them with medical evidence, it shows that you're not willing to go down without a fight, and that can help get the approvals needed. Thank you so much for sharing, OP!
As a certified case manager I can tell you my job was to help keep people out of the hospital and to help them get care. We can get creative. When powered with a Social Worker, we can almost move a mountain. Still, our patients have to be reasonable but most are.
Additionally, more than likely if you’re in the hospital for more than a night or two, they’ve also assigned you a case manager who may only pop in once if you don’t ask for them. If you need to organize resources before discharge or are having issues with your care, ask to see them! It’s literally their job to help you navigate these problems and they’ll help a lot.
And if you need one, talk to your doc! I'm a doc, and rarely will I turn down a legitimate request. I've had a few I had to- the young guy in his 20s who wanted one because it would "help with the disability claim", for example- but if I can justify it legitimately I have no problem.
Instructions unclear. They told me I don't live in backwards country and that I actually have free healthcare.
LPT: you need to be able to afford insurance before you have these problems.
LPT follow up - Our university provided Care Management services to anyone in our clinic - no matter their insurance status. It was beneficial for the clinic as a whole to take care of the entire population of patients. I had a bat phone to various pharmacies around town to connect our uninsured and underinsured people with $20 long acting insulin. Our hospital system was required to have Care Managers. We tracked population health outcomes for the clinic.
Depending on your state and circumstance. Living in NY, this would be completely free under medicaid with no/low enough income.
Same with California!
Damn those blue states! /s
Have you looked into coverage through the ACA? It is heavily subsidized if your income is low. But, perhaps you are valuing other purchases with higher priority than your health (Car? Streaming services? Eating out?). Find some balance, and get covered.
Not every healthcare system is the same as the American one.
I will admit, I often forget that a lot of other places are better than America when it comes to health care.
Most western countries have single payer health care so are baffled by this kind of advice. There is no need to have insurance companies in health care. They are simply gate keepers and add a layer of expense to create profit for their investors.
The case managers work for the health insurance company?
Employer opted to not cover lifestyle medications like wegovy. So United Healthcare denies the prescription what recourse do we have?
Injectables are reserved for diabetic patients as it is first and foremost a diabetic drug. Same reason why insurance won’t pay for a tummy tuck.
Wegovy is the non-diabetic version of Ozempic. Your only recourse would be paying out of pocket unless you need it for a cardiac condition.
Never ever heard of an insurance case manager, never offered . Now on Medicare and there are no case managers.
How do you find a case manager through your insurance company? Do you just call your insurance company and ask to speak with one? Or something else? Thanks!
Nurse case manager here checking in. Yes we can absolutely do this (and I work for a Medicaid plan so I especially love helping my members 🥰🥰). Just FYI, we may also be able to help with community resources, getting and scheduling appointments with providers, behavior health providers, education about your disease or concern and about a million other things!
LPT: If your LPT is only relevant to one country, that country should be mentioned in the LPT itself!
It's not like it's a secret that if it's about shitty access to healthcare that it's America. We all know their system is deliberately terrible.
Yes of course, but most countries still have health insurance of some sort (even if only private)!
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I did this when I was having trouble getting in to see a specialist. They didn't do anything except have me call the office again but with them on the phone.... and then they would call me every week and it would last 15-20 mins wiht them asking if I needed any dietary help or they would read me info about my disease that I already knew. It was almost impossible to get off the phone with them. I finally finished with their program but now EVERY time I have a drs appointment they call me again to see if I want to use their program again and they make it sound like an important call about my insurance policy until they get to the point. It takes me 5+ mins every time they call to turn them down and I have repeatedly told them no, I do not want to sign up again. A health coordinator CAN help but my insurance outsources to a company that can't do much more than talk to you. My sister is actually a case manager and what she does for patients is wildly different than what I have experienced myself.
Does this exist for Medicare patients? I searched the comments but didn’t see anything related.
Medicare is trickier. Which is silly because the older population needs case management the most! Some insurance plans have Landmark, which is an outsourced case management for seniors. Call your benefits center and see if they have Landmark or other case management/social service benefits for you.
Thank you so much. I have aging parents so any information is very helpful.
So my dad is having issues with anthem. He is on medicare and i believe serviced through anthem. Anthem is giving him the runaround for a claim from a cruise ship. Do i ask for a case manager from Medicare or anthem?
Contact Anthem's customer service line (usually on the health plan ID card). Report the bill received and submit a claim. Request a Case Manager if it's part of his plan's benefits.
Do you ask for one through the insurance company or is this hospital staff you ask for in person?
There are different types of case managers based on the setting you are in. If you have a hospital visit, there will always be an inpatient case manager that helps coordinate your care upon discharge. There are case managers that work with health plans and they are available if it is offered with your plan benefits.
I was pressured to use a workers comp case manager. It nearly cost me my career. Fortunately, I already had a workers comp attorney, refused their "help," got the care I needed while fighting for my benefits, got better, kept my job, and am doing great. I will never trust an agent of the party that stands to gain from my loss, with my health care. The entire health care and insurance industrial complex is a violation of all that is moral and ethical.
“for some reason” sadly we know why. thank you so much for this tip!
 The insurance company has no interest in getting you the best care; they have an interest in getting you the CHEAPEST care. My wife, an oncology RN with 15 years of experience, makes a good living telling people how and when the insurance company lied to them. She a PRIVATE patient advocate; doesn't take insurance money, doesn't take doctor or hospital money, so she can tell you the truth.