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Regional offices have autonomy, consistency
Policies and procedures are the same
The regional offices of Blue Cross Blue Shield of Arkansas each have their own identity but they follow consistent policies and procedures based on URAC standards for the company’s case management program.
Establishing consistent policies for case managers to follow is an important part of decentralizing your case management activities, says Niki Wilson, RN, CCM, HIA, manager of enterprise medical management for Blue Cross Blue Shield of Arkansas and its affiliates.
Consistent policies and procedures among the regions are essential in determining outcomes on a companywide basis, she says.
It’s difficult to do any meaningful reporting on a companywide basis when each region tabulates its cost savings a little differently, Wilson points out.
She has the responsibility of supporting the medical management programs, the medical management teams in all regions, is a facilitator for the medical management council (the quality improvement committee with oversight for case managers), handles special projects, and is the liaison with the utilization review company.
The case management program has earned URAC accreditation, from the Washington, DC-based organization, a process that Wilson calls "the best thing we ever did" because it provided consistency throughout the region for documentation of case management outcomes and calculating savings from case management interventions.
The URAC accreditation came about as a result of the case management relationship with the Federal Employee Program, which applied for URAC accreditation.
The insurer was required to become compliant with the standards but wasn’t required to become URAC-accredited.
"We took it a step further and went through accreditation for all our lines of business," she says.
The regions have a lot of autonomy by necessity because there is a different customers base in each region and different community needs and services.
For instance, the northeast region has taken an active role in community wellness programs, and the staff work closely with employer groups to set up health fairs and other projects that promote wellness.
In the central region, the case managers work closely with the employer groups.
When they begin working with a new employer group, the case managers do a focused report, determining the top 10 problems that particular group may have.
For instance, some populations have a lot of diabetes or coronary artery disease. In those cases, the case managers work with the group to try to get members enrolled in an appropriate disease management program. They work with them on health fairs and make "lunch-and-learn" presentations for the employees.
All of the regional case managers know each other and frequently call each other and collaborate on care.
They get together for quarterly meetings coordinated by Wilson. Each meeting includes educational presentations for which the case managers can earn the CE credits necessary to maintain their certified case manager (CCM) certification.
The case managers are required to get and maintain their CCM certification. If they aren’t certified when they are hired, they are required to become eligible to sit for the examination with two years. The company pays for the certification process and reimburses case managers for continuing education. CCM certification requires 80 hours of CE over a five-year period to maintain it.
The quarterly meetings include continuing education, time for the case managers to share programs they have developed in their own communities, and opportunities for the case managers to visit with their fellow case managers.
"The quarterly meetings also are our opportunity to keep the case managers up to date about any changes going on in the company," Wilson says.
The company’s case managers work with all different lines of the company’s business, including the HMO, PPO, indemnity, and TPA for the self-insured.
"It’s a real challenge for anyone coming in new to learn insurance and the different lines of business. Each line of business has different benefits for the case manager to handle," Wilson says.