managed care,HMO,rationing health care

  1. I would like to know how insurance companies defend decisions to deny care. Do they have any standardized references to guide decisions? I am interested in the decision-making process for multi-system failure elderly patients with minimal positive outcomes from intensive nursing.
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  2. 8 Comments

  3. by   nursedude
    I must say that your question seems a little silly... Sorry, I don't mean to sound condescending but get with the program...! First of all insurance companies base thier decisions for the most part on completely legal guidlines- there are thousands of them... Look up "Milliman and Roberts". These are the names of 2 doctors who came out with the first set of guidelines for the "length of stay" guidlines for medical/surgical diagnosis'. You know, d/c from hospital 1 day post vag delivery- THESE GUYS ARE DOCTORS!!! Managed care companies do everything by the book-at least they are supposed to. They follow all medicare guidelines etc...

    Insurance companies are huge-so are thier lawyers. They have more money at the insurance companies than all the hospitals combined...
  4. by   suellen e.
    We know how managed care operates and that at least one CEO I read about makes $937 million annually. We have all seen the injustices that seem to be a consequence of managed care such as treatment delays for young children with malignant tumors...the question we face now is what can we do about changing the situation we are all in? How can we best give our patients the kind of quality care we have learned to provide them and maintain our own sanity and health in the process? I work with doctors and nurses who are working longer and harder every day, with larger numbers of people to care for. There doesn't seem to be enough time to explain what thyroid disease is and symptoms to watch for or to get a PTT result for a patient with DVT and make ends meet in the office. How are we going to handle the situation we're in now?
  5. by   mn nurse
    Sorry to drag up an old topic, but I came across this while reading some back postings and couldn't resist!

    I have worked in case management for several years, both on the provider side and the payer side. It's interesting to see the vast differences in viewpoint.

    Yes, there are gajillions of regulations governing denial of coverage for medical care. Most come down to either not meeting criteria for medical necessity or else the request is for services specifically excluded in the member's certificate of coverage. When a denial is issued, there are complex policies and procedures to be followed, a Medical Director reviews and cosigns every denial, and I then call the patient's doctor, Case Manager or Social Worker, and the member, or their designated contact, to discuss why the service is noncoverable, what their appeal rights are, and encourage them to exercise those rights. I give them my name and phone number, so the information isn't dumped on them by some impersonal big business entity. They are also sent a letter with the information in writing to refer to later, letter sent by courrier, if the urgency of the situation warrants it. In some states, the member can sue for damages related to negative outcomes caused by a decision of noncoverage. We don't have that in MN yet, but I have a feeling it's coming. Nobody has anything to gain by a "bad" denial; it just causes the patient's condition to worsen, causing more trouble and expense for eveyone.

    Please remember, the insurance contract is one entered into voluntarily by the member, and they share some responsibilities for understanding its terms and conditions, just like any other contract a person might sign.
    Insurance is also business, and although I don't make millions of dollars a year (trust me, I don't!) the executives of insurance companies have the same opportunities as big business execs anyplace else. Does the name Bill Gates ring a bell?

    In relation to the original question regarding multisystem failure in the elderly... In the absence of the ability to improve or cure, they have the right to maintain their level of health and function (whatever that level may be) or, if that's not possible, to be assisted through a comfortable and dignified death. If your patients do not have a Case Manager at the insurance company assigned to them, I would encourage you to help them get one. These Case Managers know that what's good medicine is generally what's most cost effective, and they also are generally pretty knowledgeable about other resources out there. One of the frustrations I have is being contacted by providers late in the decision making process. If I know early on what's going on and what plans and options are being considered, I can help more than if I'm not called until the day of discharge.


  6. by   suellen e.
    Dear mn, Thank you for your reply. I never knew that case managers were available at the insurance company end for patients. But one doesn't have a choice about the manager, does one? I guess it's luck of the draw. As you say: the patient signs up with an insurance company and so it behooves the patient to understand the terms of the policy. Well, two things about that: 1) The patient signing on with a company may be an employee of a company, and so does not have a choice about the health group to joined (this was the case for me - the going program for healthcare in our medical group was Health Net. 2) If it is a responsibility of those covered to understand the terms of the insurance policy which provides payment for their healthcare, what do you have to say about the insurance company that changes its policies mid-stream, for example changing the formulary lists, or changing the method in which a physician must get permission to use a non-formulary drug for a patient?
    I'm glad to have you here to shed light on these perplexing issues. Please stay tuned.
  7. by   nursedude
    Yes,

    Here I am again playing what else but Devil's advocate. I too used to be a case manager for an insurance company and yes, I did make a difference in quite a bit of peoples lives and yes it is a good idea to have a case manager but....

    The problem is this, when I worked as a case manager for the insurance company- I WORKED FOR THE INSURANCE COMPANY... At both of these companies the biggest and most important part of my job was not patient care, or making the members happy but COST SAVINGS.

    COST SAVINGS, COST SAVINGS, COST SAVINGS...

    My boss (another RN) didn't care if the members got their transplants or chemo or physical therapy, her boss(another RN) didn't care either and her boss (a MD/PHD) didn't give a rat's rear end about little Johnny or Suzie or anybody either, but what did concern these people was "if I met my cost savings for the week/month/year". If I met a certain amount of cost savings q/month and all the other "Case Managers" met their's then that meant nice juicy bonuses for the higher ups...COST SAVINGS is what drives managed care, it's why Utilization Review and Case management(at the insurance company) exist.

    Again, it is a good idea to have a case manager at the ins company but remember who they really work for...
  8. by   nursedude
    One more point...In regard to your suellen's posting.

    I think that there are a lot of people out there who somehow assume that medical insurance is a right (like the right to vote). My feeling is that medical insurance is not a right. I think that many americans believe that it is up to someone else(their insurance company or the government) to provide this service.

    A little over 100 years ago medical insurance did not exist. People paid for the services provided from doctors and hospitals outright from their own bank accounts. Medical insurance was invented as an additional form of payment or a bonus to working for a certain emplorer. Kaiser Permanente is an example of this. Mr Kaiser was a businessman/contractor. He wanted to make sure that his employees showed up for work everyday and that they were not calling in sick all the time so he contracted with a Physician who agreed to provide medical care for Kaiser's employees(for a price).

    I guess what I am saying is that there are a couple of points of view about medical insurance and I think that it is a good idea that the insured member carry at least a little responsibility in what his employer is trying to provide for him.

    Again, the insurance companies clients are not people. Their clients are employers.

    Also, how about a hospital that is an HMO that is an employer???

    Look at: http://www.upmc.edu/upmchealthplan /

    How would you like to work for an employer that is also your hospital and also your insurance company? Your PCP is not only contracted with your HMO(which is your employer and your hospital) but he works for the HMO directly. Who makes the decisions for these employees? Their employer or their HMO? When their PCP makes decisions about their care is the PCP making those decisions as a PCP or as a physician employed by an HMO?

    I think Suellen, that it is clear... The only choice employees have is A) work for a different employer or B)pay for your own insurance.
  9. by   askater
    I don't know why hospitalization is declining.

    I worked at one hospital their goals were MONEY SAVING and not proper care of the patient. I hated it. My supervisor and administration we're making CUTS...CUTS...CUTS.... I obviously left. With all the cuts I couldn't give proper patient care.

    Patients and families notice cuts in hospital care. And believe me patients talk. When people asked where I worked. I told them. They told me how much they hated that hospital and would never set foot in that hospital. I don't blame them. I wouldn't let my family go to that hospital electively. And if they have to I will NOT leave there bedside.

    Hospitals and insurance companies need to stop just looking at cutting cost. Hospital care is getting very poor. One day their family will be in the hospitals. I'm sure they'll want their family to get good care.
  10. by   tlf91
    Quote from mn nurse
    Sorry to drag up an old topic, but I came across this while reading some back postings and couldn't resist!

    I have worked in case management for several years, both on the provider side and the payer side. It's interesting to see the vast differences in viewpoint.

    Yes, there are gajillions of regulations governing denial of coverage for medical care. Most come down to either not meeting criteria for medical necessity or else the request is for services specifically excluded in the member's certificate of coverage. When a denial is issued, there are complex policies and procedures to be followed, a Medical Director reviews and cosigns every denial, and I then call the patient's doctor, Case Manager or Social Worker, and the member, or their designated contact, to discuss why the service is noncoverable, what their appeal rights are, and encourage them to exercise those rights. I give them my name and phone number, so the information isn't dumped on them by some impersonal big business entity. They are also sent a letter with the information in writing to refer to later, letter sent by courrier, if the urgency of the situation warrants it. In some states, the member can sue for damages related to negative outcomes caused by a decision of noncoverage. We don't have that in MN yet, but I have a feeling it's coming. Nobody has anything to gain by a "bad" denial; it just causes the patient's condition to worsen, causing more trouble and expense for eveyone.

    Please remember, the insurance contract is one entered into voluntarily by the member, and they share some responsibilities for understanding its terms and conditions, just like any other contract a person might sign.
    Insurance is also business, and although I don't make millions of dollars a year (trust me, I don't!) the executives of insurance companies have the same opportunities as big business execs anyplace else. Does the name Bill Gates ring a bell?

    In relation to the original question regarding multisystem failure in the elderly... In the absence of the ability to improve or cure, they have the right to maintain their level of health and function (whatever that level may be) or, if that's not possible, to be assisted through a comfortable and dignified death. If your patients do not have a Case Manager at the insurance company assigned to them, I would encourage you to help them get one. These Case Managers know that what's good medicine is generally what's most cost effective, and they also are generally pretty knowledgeable about other resources out there. One of the frustrations I have is being contacted by providers late in the decision making process. If I know early on what's going on and what plans and options are being considered, I can help more than if I'm not called until the day of discharge.

    At present the company I work for pays out 97 cents from every dollars brought in. Very good response. Could not have explained it better.

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