Do Medical Directors really review clinicals?

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    Hi, My family member has a PPO with a large insurance company in USA. She needs OT, ST and PT and is making remarkable progress in all 3 (neuro recovery). She's exhausted her benefits but has been approved for additional visits this year, which she has also exhausted. She applied for more visits this month with the nurse case manager team and the team has given us totally conflicting answers in the past week. The answers went from denied extra visits, to approved extra visits 7 days later (with a new auth number) to denied again only 24 hours later. What is going on? They told us the same medical director gave all 3 answers. Is the medical director really reviewing the clinicals? Any shared experiences would be greatly, greatly appreciated.
    And I've read some of the threads here where some nurse case managers who help their patients, feel under appreciated and get no thanks. That's such a shame. I am so sorry for anyone who treats you like that because any of you telephonic csae managers who are kind enough to help us patients and caretakers are truly ANGELS! You have no idea! So I thank you 1 gazillion times , on behalf of the people who never thanked you!
  2. 3 Comments so far...

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    i am sorry that you are having such problems, but i do not understand how anybody on here can give you advice on your case. we are not privy to the information of your case and are not actively involved. any thoughts on our part would be pure speculation. i suggest talking directly to the ur and/or case manager on the case. he/she can explain why your case was denied (in detail) and if there is an appeal process.
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    I have studied with the CMSA Core Curriculum book and the A Case Management Study Guide. I went through all the questions. What I found was that the questions were not similar to the ones in the book and I did not like the answers. I also reviewed the cmsa website regarding what was on the test. If anyone knows of a website that is helpful or a book that is helpful, please let me know. Thank you.
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    If I find that the clinical I receive from the facility doesn't meet criteria for the guidelines we use (Milliman and Interqual), then I first call the facility CM back and ask if they have anymore clinical or anything more pertinent that I can use to qualify the stay/visits. If they aren't able to give me something that will meet criteria, then I send the case on to the medical director. He does read over the clinical and the case notes and makes his decision according to the guidelines. If you aren't happy with the decision, you can appeal.


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