Insurance CM's being used as internal "staffing" agency, since our work "can wait&quo

  1. hi everyone!! i hope someone out there can help me. i'm hot, and trying to build ammunition against unfair treatment by my employer.

    here's the situation. at my publicly traded bcbs plan, the case management dept is integrated into the um department. we are regularly "used" to perform um inpatient review on a regular basis, even to the point of a policy being set up showing us as the first coverage for any um person who is off on any particular day. we consequently end up performing an entire um nurses' assignment which includes utilization review for approx 15-25 inpatients on any given day, including performing discharge planning follow up and data entry.

    we handle hmo cases and are subject to ncqa guidelines, but also traditional/pos/ppo plans which are subject to urac um and cm guidelines. cm staffing policy allow 1 1/2 cm's for the number of members in our plan we are managing, which includes medicaid hmo members. the cm's number 1 1/2 exactly, with the second cm also doing 1/2 of her job as a disease management coordinator.

    not only do we cover um, but when the other cm is off, we may cover the other cm and a um person as well, which includes the disease management program. after study, i have found, that over the last year, we have been short from 50-75% of all business days.

    our cm guidelines include complex members with social issues, ongoing home health assessment/authorization for complex members, catstrophic case management, skilled nursing facility review and dcp, acute rehabilitation review and dcp, rate negotiation for any member going outside the network, and identifying members proactively to intervene and educate in hopes of preventing hospitalizations/deterioration of conditions. our cm is suffering as a result. complaints fall on deaf ears, when our supervisors continue like a "broken record" to say that our cm work "can wait" while we do um functions. i can't seem to convince my manager that when we are busy doing um functions, i can't just put aside the member with the trach, who's face is swelling up so his eyes are closed, has a temp of 102 and whos wife has a fist full of referrals to specialists, but has no idea what to do with them, or the member in pain, requesting a case manager, who becomes our member tomorrow, has never seen her primary physician in our plan, and is out of meds. or the diabetic at home with a non healing wound who also has behavioral health issues, and can't figure out who to call or what to do when her sugar is >400.

    meanwhile, members are calling, cases are piling up, negotiations with nonpar providers for future surgery, calls which should have been made to ensure transition to home/referrals/services are in place and there are no ongoing needs are not being done. i am quite concerned, because our cm policy includes quite specifically, frequencies of contact, frequencies of documentation, certain things that have to be done at certain times, and i think that we are taking legal risks here for both ourselves and the company.

    it is my thought that if a patient suffered as a result of us not following through on some part of a plan, we would be responsible for our cm policy, urac cm guidelines and ncqa standards to a court of law, regardless of staffing. our cmc certification i assume would hold us to a certain standard. does anyone have any thoughts about our legal risk?

    does anyone out there have any idea where staffing models for cm might be found? my employer expects a caseload of 60-80 cm members, and staffs at this ratio:
    1 cm for each 50,000 medicaid members
    1 cm for each 100,000 commercial hmo members
    1 cm for each 175,000 ppo/indemnity/pos members

    i have asked to speak to legal about risk and have been directed to human resources, and suddenly we were all asked to sign forms agreeing that we have read and understand our state nurse practice act, ncqa and urac standards, as well as confidentiality policy.(which, btw, my manager tells me to ignore in certain situations from time to time)

    thanks for your time and comments. any assistance would be greatly appreciated!!!

    norweaver
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  2. 1 Comments

  3. by   AnneTheNurse
    Dear Norweaver --

    I would recommend complaining to the following certification agencies -- NCQA, URAC, the state agencies which oversee Medicare, Medicaid and HMO's in your state, as well as the state insurance commissioner. You might alway want to contact the Board of Nursing in your state to make sure your licensure is safe under your state's nurse practice act. I wouldn't sign anything until you have checked with your board of nursing. It sounds like your employer, like most large insurance companies, wants to maximize it's income with a minimum of staff. Good luck to you!

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