Transplant case begins with eligibility verification

CMs help find resources for family

The first step in a typical transplant case for Regence Blue Cross and Blue Shield of Oregon’s transplant case managers is to verify that the member is eligible for the transplant.

Some of the plans have a 24-month waiting period before the transplant benefit takes effect. However, Regence gives members credit for any insurance coverage, and in 3½ years, there have been only two people who were not eligible, Wrigley says.

"Once we have established their eligibility, we determine whether a transplant is medically appropriate and meets our policy for medical necessity," Ferrell says.

There often are complicating factors in transplant patients. For instance, people who need a kidney transplant typically have so many comorbid conditions that they may need to lose weight before the transplant.

If a liver transplant patient still is using drugs and alcohol, the case managers work with the transplant facility to impose restrictions, such as waiting six months to a year with random testing.

The case managers rarely get involved in compliance issues because transplant centers won’t approve the procedure if the patients aren’t compliant. "They [transplant centers] are coordinating all the care, the tests, the scheduling, and dealing with any compliance issues," Farrell says.

Sometimes the patients may need transplants that involve such cutting-edge technology that they are considered investigational, she says. "Occasionally, we have to deny a transplant, but it isn’t very often. When it doesn’t meet our regular medical policy, we look to see if there are clinical trials that we can support."

Farrell says the most frustrating part of her job happens when a patient needs a bone marrow transplant from an unrelated donor. The search for a compatible donor often is not covered by the health care benefit she says.

The case managers often have to tell the patients that they will cover the procurement and the bone marrow infusion but not the search. They then refer them to the social worker at the transplant facility who may be able to help them find funding for the search.

"We help them get hooked into resources as fast as possible and they usually cope with it. The cost of the search is a small piece compared to what we are paying for the transplant. That doesn’t make us feel any better when we tell people no, but it is the way I can sleep at night," Farrell says.