Insurance Case Manager?

Does anyone use one?  I had a call last week from a nurse that says she's a case manager from my insurance company.  She didn't say why she was calling, but I guess that's obvious.  I called her back but haven't reached her yet.

Does anyone know if I have to accept a case manager?  The reason I ask is because I've had this disease for so many years, I hate to have someone who knows less about it than I do calling the shots (it's bad enough that some of my doctors have to be educated ;0). The idea that this nurse is being paid by my insurance makes her suspect from the get go, especially as far as maybe getting the tests I may need if they're expensive? 

I don't know, it may be a good thing as my insurance can take a long time to approve referrals and hopefully this would speed things up, but I'm not sure how much power they have. 

Then I'm wondering what happens if we don't see eye to eye, or if I plain don't like her, or she doesn't like me? 

Any info would be appreciated.

I do have one of these case managers. She was the one that called me 2 months after this insurance was my primary...after I lost my better insurance thru my job I had at the time...and told me that this insuracne doesnt cover ostomy supplies then tells me of a place that is 40% off. This was at the point when my reversal was set up and I had plentay at home to get me to the surgery. I was pretty ticked at her back then. I had a visiting nurse at the time who was changing the wound vac dressing. That nurse continued to come after the vac was gone since I still had the abscess drain in. She started giving my home care nurse the 3rd degree about why she had to be at my house. I was so upset at that point from the case manager nurse since she was throwing all of this at me when I should have been told the info she was giving me when my husband told his work that this would now be my primary insurance. I had never had one of these before but was assigned one after my hospital stay.

They are so on the ball there that I got a call in November after my first stay they kept asking for my husband who was at work and were not telling me what it was about. Well the info she was given was that it was my husband in the hospital. She has helped me more recently though. She kept calling and helping my fight with Medco for the authorization of my humira. My dose was doubled from the traditional maintanence dose to help my fistula. Since the whole issue was pending and ammended and denied again and all those issues they were not allowing me to even get my old dosage which I was due for. I had also told her about the issue with the person inputting the CD starter pack in as a 3 month supply and they were giving me issues saying that even tho they messed up they needed authorization from my doc to fix it. Screwball morons ...sry I HATE medco. I get the meds at my local pharmacy I dont mail away for any meds since I never know if doses will change or if I will not be on it long etc.

I still think she has issues with me but I have so many bills they didnt pay for cuz they also didnt tell me til 2 months later that I needed a letter of termination of my old health insurance so that they would be my primary and only health insurance. I have dealt with CS there and they kept saying ok dont tell me any more bills dates, type of appt etc they said we will just go back and all will be fixed in 1 month. It wasnt fixed not 1 part of it....My husband went on a conference call with my case manager nurse and a CS person for my health insurance. I felt maybe if my husband got on the phone...he is the holder of the insurance...plus the case manager that maybe some stuff would get finished. After my husband went thru all of it with her, she did tell him to stop at one point but didnt give him the run around as the CS did to me I also had gotten hung up on b4. Then when they were caught up with apps he went thru then he continues with more of the bills...Afterwards I spoke with her and informed her of what occurred with me when I spoke with someone and I knew the date so the person I spoke with was documented in the computer.

It was a pain in the begining but she has helped a lot especially with my Humira

they are only trying to help

My insurance had one calling me last year all the time when I was having repeated hospital admissions. She really didn't know anything about CD or my meds. I kept telling her there really wasn't any info that she could give me that I didn't already have. Finally after several very long phone calls, most during the dinner hour I might add, she agreed that she really wouldn't have much to offer me. However, when I was trying to get transfered out of my local hospital into the bigger hospital in the city so I could get a test done quicker (I was already inpatient, and as an outpatient at the larger hospital I was going to have to wait 2 months), I was able to call her and have her try to help speed the process up. I also see the cheif of GI at that hospital and was calling his office. So in the long run, I'm not sure who was really the one who got me transfered, but I'm glad I didn't totally burn my bridges.

Of course a few months later I got sort of a nasty letter saying I was being dropped from the program because I didn't return this woman's calls. I have caller ID on both my home and cell phones. She had never called me. NOT once. So I think she just didn't want to deal with someone she knew she couldn't help.

Judy...I work for the insurance industry. Some RN case managers can be fantastic and others are not so good. It's the same as everything lese in this world. Sometimes it is beneficial to have one involved because they can be your advocate in getting care approved (usually because it is more cost effective for the health plan though).

You can work with one as much as you chose or chose not to have a manager at all. I chose not to have one--I have concerns (real or perceived???) that any more knowledge of my disease may be reflected to my job. I also had some negative experiences with my carrier and the nurses that I have called.

I have worked with RN case managers that helped their patients find local care when needed, less expensive alternatives for DMe etc. You may have a case manager assigned when you are admitted so they can follow your hospital stay. They will often help to get you discharged or get additional days approved.

It all depends on your carriers parameters for the managers and the person you get. If you decide to use the assistance, you can always ask for a new manager or decide to cancel your participation. You may want to try it to have another outlet for info and work from there.

I have not been offered a nurse case manager but this is what I gathered from reading my policy info: once someone is diagnosed with chronic illness it is more beneficial (cost wise and compassion wise) for that person to be treated properly from the get go then to not be treated and let it get out of control. So, often, a nurse case manager will be assigned to make sure you understand what you have and how to properly follow your doctors directions. I just get letters in the mail when I am do for a refill. It just says something like "we are reminding you that it is very important to take your medication as directed, please refill soon..." I could see this person being used in your benefit if your doctor suggests something not usually approved and your nurse manager can say "this is necessary to manage her disease and will cost you less in the long run." However, I could see it hurting if you disagree with something your doc recommends and you get labeled as a "non-compliant" patient.

Habs- I understand you don't want your career to be placed in jeopardy. Do you work for the same company that insures you? In regular insurance/business contracts it is highly ILLEGAL for them to mention any of your confidential health information to your employer. Even if you work for that company I would think it would violate HIPPA regulations. I guess it would be awkward if you all shared claimant information as part of your employment and you just happened to be one of those claimants. . .

My insurance company tried to get me to sign up for that. I told them I had enough people weighing in on my care, and adding someone else to the mix was too much in my book.