Advocating means being a good steward

Keep limits to coverage in mind

Being an advocate for your patients is more than just trying to get them every treatment available. It's being a good steward of their healthcare funds so they'll have benefits for treatments in the future, says B.K. Kizziar, RN-BC, CCM, CLP, owner of B.K. & Associates, a Southlake, TX, case management consulting firm.

"Nobody has an unlimited bucket of resources," Kizziar says. "Case managers in all practice areas should be aware that patients are going to have needs after this particular episode of care and conserve their resources whenever possible."

The first step in the process is to be informed about your patients' benefits and resources and develop a plan to make them work for the best possible transition of care, she adds. Look at your patients' lifetime benefits while developing a treatment plan, Kizziar says. "For instance, if a chronically ill patient needs home care, look at the annual limit on home care visits. It might be wonderful if he could get five visits a week but if the limit is only 20 for the whole year, suggest the minimum he can get by with so he'll have funding to last the rest of the year," she suggests.

Remember that even when a patient has no lifetime maximum, that doesn't mean he or she has a blank check for healthcare costs. Even unlimited lifetime benefits usually have some kind of annual maximum, Kizziar points out. "Case managers should be concerned about doing the right thing for the patient at one particular time. Patients don't necessarily need a comprehensive total work up if they come in for one particular ailment. Part of the role of case managers is to partner with the physician to ensure that patients get what they need to transition as smoothly and appropriately as possible," she says.

Case managers should ensure that their patients know all the options for care and become actively engaged in the healthcare process and decision making. They should also provide the information they need to make informed decisions, she says.

Beware of making personal judgments about what patients can or can't afford if their insurance doesn't cover a particular service, says John Banja, PhD, professor, Department of Rehabilitation Medicine, and a medical ethicist at the Center for Ethics at Emory University in Atlanta. "Often healthcare professionals make up their mind as to how much patients can afford, and they don't mention a modality if they think the client can't afford it. This is always a mistake. You never know what the client or patient has in the way or resources. Case managers should always inform the patient about whatever reasonable options there are and not make judgments about what he or she can afford," Banja says.

For example, if a patient could benefit from home care but doesn't have coverage for it, talk to the family. They might be able to find a way to pay for it. Kizziar says, "In healthcare we tend to think we know what is best for our clients, and we have made them dependent on us. But with the changing healthcare environment, it's critical to help them become more engaged in their own care plans. This means giving them more information about what is covered and what is not, and giving them the option, and letting them make their own decisions," Kizziar says. Doing otherwise takes the decision process away from the patients, she adds.

In some cases, when spending a little more now can save a lot more later, providers and payers might be able to work out a way for patients to get what they need, Banja says. For example, a patient might have a limit of 10 physical therapy benefits, but when he is reaching the limit, the case manager sees that he is doing so well that if he has five more visits, he could be entirely fit to return to work and avoid reinjuring himself. In this case, not only would the patient benefit, the third-party payer also might benefit by saving money down the road, he says.

"The case manager could make a plea for the insurer to cover extra visits. If that doesn't work, she could ask if the physical therapist would give a self-pay patient a discount and ask the patient if he's willing to pay a reduced rate out of pocket," Banja suggests.