Insurance assigns a Case Nurse....nice or a trap?

[gina171 626]

Hmmm....I have United Healthcare Choice Plus, bariatrics surgery is covered given my BMI, but one of the extras of my coverage is to have a case nurse assigned to you (can be for ANY medical situation, not just bariatrics) who will help you move through the process and be a more direct liaison...sounds nice.

But....to set up there's a 45 min appt over the phone where u give an complete health history. My appt is tomorrow.

I might be paranoid but I can't help but worry is there some way my insurance is trying to get this info and then trip up my process and find a reason to deny me?

Maybe this is a nice benefit, I don't know. My husband works for a pharma company and we typically get great healthcare plans offered to us, so this might be legit. Or it could not be, I don't want to misstep accidentally and ruin my coverage.

Am I paranoid? Or should I cancel this phone intake appt, and not get a case worker til I am approved?

Thx

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Edited May 23, 2016 by gina171

[Diana_in_Philly 1,426]

United offers this for "chronic" conditions. I was offered one for my asthma when I had UHC. I refused. I have a perfectly good team of physicians who have examined me and know my situation. I don't need a nurse on the phone five states away to tell me to call my doctor to answer a question she couldn't possibly answer. Carriers do this to try to cut costs, because many patients with chronic conditions (asthma, diabetes, high blood pressure, etc.) wind up costing the carriers significantly in unnecessary ER visits and hospitalizations because they do not understand their condition or work consistently with their medical team. It really is up to you. If it were me, I'd say thanks but no thanks. Just my opinion.

[Icantbelieveit 955]

I woukd respectfully decline.

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[KristenLe 5,979]

@@gina171 I would decline as well. They usually assign Care Managers for High Risk/Complicated patients (insurances consider high cost - high risk). I don't see there would be any benefit to you at all in this situation. I wouldn't hesitate to ask them if declining the Care Manager was going to put your approval in jeopardy (I don't believe that would be legal when you have the coverage). Nurse Care Managers can be very helpful when you have barriers to care or for self management education for a chronic disease - I don't see how they would be helpful in this case - other than to drive you mad!

[gina171 626]

Thx! Cancelling the phone appt!!!

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[Anna Nim 196]

[Icantbelieveit 955]

Lmao

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[MissMac 163]

If it were United Health Care that I had years ago, I would say run away in the opposite direction as fast as you can.

However, when I had that darn stroke, my current insurance BCBS Federal offered a case manager. Since I had to have help with therapy, home health care, and having a Power of Attorney handle major decisions for me, the Case Manager was a gift from God.

She helped us navigate through all that mess and gave us ONE person to talk to when dealing with the red tape. I was not punished or denied care in any way. So, I would say it depends on which carrier you have.

[NikkiDoc 312]

I had one assigned. She just really wanted to make sure I really understood the whole process. The process included the approval process, the nutrition, the surgery and that I was using an approved surgeon and facility.

How many times on this forum have we seen people that are surprised by the pre-op diet and the post-op eating restrictions? It was her job to help make sure that doesn't happen.

I was well educated prior to my first visit with my surgeon so my case nurse didn't need to do much.

I have worked in health insurance for 25+ years. I generally like when case management is involved. I have seen numerous times where the case manager has helped a patient by being an advocate for that patient. One case the person was a cancer patient and was constantly nauseous. The oncology office was blowing the patient off. The nurse helped the patient by suggesting diet changes to foods that were less likely to upset their stomach and pushed the doctor's office to prescribe an anti-nausea drug.

I have seen where the nurse case manager encourages a second opinion so that the patient is comfortable with their options.

I have never seen where case management is used to "trap" somebody to get something denied.

Many patients have a tough time navigating the health care system. The case management nurses will review the proposed care and make sure that what you are having done will be covered under insurance. If it isn't going to be covered they let you and your doctor's know before you incur the expense rather than you getting stuck with an unexpected bill.

For bariatric surgery my case manager made sure to stress that I had to have the monthly visits for 6 months for my pre-op managed diet. She was clear about what clearances I needed to get my approval.

For what it is worth once I got all my clearances pre-op my surgeon's office submitted the pre-authorization request on a Tuesday and I had approval Thursday the same week. It went smoothly because everyone was on the same page about what the insurance company needed for the approvals.

I had one assigned. She just really wanted to make sure I really understood the whole process. The process included the approval process, the nutrition, the surgery and that I was using an approved surgeon and facility.

How many times on this forum have we seen people that are surprised by the pre-op diet and the post-op eating restrictions? It was her job to help make sure that doesn't happen.

I was well educated prior to my first visit with my surgeon so my case nurse didn't need to do much.

I have worked in health insurance for 25+ years. I generally like when case management is involved. I have seen numerous times where the case manager has helped a patient by being an advocate for that patient. One case the person was a cancer patient and was constantly nauseous. The oncology office was blowing the patient off. The nurse helped the patient by suggesting diet changes to foods that were less likely to upset their stomach and pushed the doctor's office to prescribe an anti-nausea drug.

I have seen where the nurse case manager encourages a second opinion so that the patient is comfortable with their options.

I have never seen where case management is used to "trap" somebody to get something denied.

Many patients have a tough time navigating the health care system. The case management nurses will review the proposed care and make sure that what you are having done will be covered under insurance. If it isn't going to be covered they let you and your doctor's know before you incur the expense rather than you getting stuck with an unexpected bill.

For bariatric surgery my case manager made sure to stress that I had to have the monthly visits for 6 months for my pre-op managed diet. She was clear about what clearances I needed to get my approval.

For what it is worth once I got all my clearances pre-op my surgeon's office submitted the pre-authorization request on a Tuesday and I had approval Thursday the same week. It went smoothly because everyone was on the same page about what the insurance company needed for the approvals.

[Inner Surfer Girl 12,015]

From all the issues people seem to have with insurance, it seems to me a case manager would be very valuable in helping to navigate the bureaucracy and red tape. A single point of contact with someone who knows your case would be helpful for both you and the insurance company.

[Jenjen2016 32]

I like my case manager. It's nice to have support from someone other than family who can be bias. I like having someone to talk to about it all also.

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[j16 166]

Hmm - I was offered one by BCBS but never responded to the letter. I had already been approved without any problems. I just figured an insurance company is never going to offer anything unless there is a financial incentive involved.

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[Sajijoma 1,324]

I had one assigned through my husband's work. They have their own plan but it's administered through Aetna . She was helpful! We went over history and stuff and then she talked to me about possible medications, side effects to watch out for, gave me a number to call if I needed extended stay in the hospital beyond the 1 day insurance allotted-which I did use, and ahe called after my surgery to check to see if my needs were being met and my pain managed and reminded me not to shave while on blood thinners because it could be disastrous....but it was good to know! I never thought of that one!

[gina171 626]

Sajijoma, that's deftly the way my plan works too...a self-funded company plan that's administered through UHC.

Is yours a pharma company, too?

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[Sajijoma 1,324]

No aeronautics with a huge global company. But the liaison is really helpful.