Regional offices bring CMs closer to clients

Care is targeted to regions’ specific needs

It’s not unusual for members covered by Blue Cross Blue Shield of Arkansas to drop by the office and visit their case manager in person.

"Many times, we have members who are coming into the city for a doctor visit and they stop by the office and visit their case manager," says Niki Wilson, RN, CCM, HIA, manager of enterprise medical management for Arkansas Blue Cross Blue Shield and its affiliates.

This close relationship between case managers and clients has occurred since the Little Rock-based insurer set up seven regional offices, located throughout Arkansas.

Each office is full service, with marketing and customer service, a medical management team that includes a full- or part-time medical director, a full-time or part-time medical affairs manager, and one to eight RN and CCM-certified case managers, depending on the size of the region.

The insurer moved to comprehensive regional offices in 1995 and decentralized case management when the regional offices opened.

Prior to that time, the company had small offices located throughout Arkansas with staff who primarily worked in marketing. Case managers worked out of Little Rock and traveled to the regions they were assigned to handle.

"We regionalized so we could get closer to the customer. Even though we are a very small state, the regions have very different markets," Wilson says.

Members may call the customer service office in their region, or they can walk into the office to talk to a customer service representative. "The people who work in the regional offices have lived and worked in the area. They are familiar with the physicians and hospitals and have developed a working relationship with them," she says.

Working in regional offices gives the case managers an opportunity to build collaborative relationships with the physician community. Many of them have worked in local hospitals before joining Blue Cross and already have relationships with local physicians and the facilities, Wilson says.

"Those who live in the area have an instant rapport with the hospitals and physicians," she says.

They have the additional advantage of being familiar with the employer groups in their area.

"The fact that they are familiar with everyone in their community is one of the reasons we put the case managers in the region," Wilson says.

The case managers do on-site as well as telephone case management, working closely with the local providers. The case managers use their clinical judgment and experience with the health care team and home care vendors to determine when an on-site hospital or home visit is appropriate. A home or hospital visit is strongly encouraged if the case is open 30 days or longer and is required for particular types of cases, such as patients who are ventilator-dependent, who have been catastrophically injured, or who are potentially noncompliant.

The insurer did away with precertification two years ago. "When we did that, we had a relationship built with the hospitals and, as a trade-off, they agreed to give us the hospital census so we could determine which patients were appropriate for case management," Wilson says.

The case managers work closely with the hospital to review the census of members covered by the different product lines and get their primary referrals from the hospital.

When patients are in case management for a long time, the case managers do home visits, working closely with the home health agency and other home care providers.

They identify the benefits and coordinate care, working within the benefits to make sure they maximize the care the patients can get with their benefits package.

The case managers also handle case management outside of Arkansas for large national accounts.

"Our case managers have the advantage of working with case managers in other Blue Cross plans to coordinate care for members who are not in Arkansas," Wilson says.

If a case manager needs to find a home infusion therapy company in another state, he or she contacts the local Blue Cross plan to find out with whom they contract. If the plan doesn’t have a contract with a company, the Arkansas case manager negotiates the rate.

The insurer has always had a vendor to do pre-certification so the company’s case managers won’t be the ones approving or denying care.

"We wanted specifically to keep the utilization review and case management roles separate," she says.

The case managers still work on educating the physicians in their region about their role and what they can do to make the physicians’ lives easier.

"The more we get into disease management, wellness, and prevention, the more collaborative relationships we are going to be able to develop with physicians," Wilson says.

Little turnover in CM program

The case management program has little turnover. About 75% of the case managers who worked for the company when the regional offices were established are still there. A few have retired. Others have moved out of state.

Employer groups may have a corporate office in one region and employees living in other regions. The case managers work closely to make sure the care is consistent.

"They all know each other and work closely together. Our case management system is set up so that if one case manager wants another to consult on a case, they can have access to each other’s files," Wilson says. "They all know each other and always feel very comfortable in calling each other," she explains.

Four offices have full-time medical directors. The medical directors are responsible for clinical oversight and are available to the case managers if they have any problems with cases. For instance, the case managers may call on them for help with difficult decisions or to intervene if they think that a local physician would respond better to another physician.

Each regional office has developed a regional medical management committee made up of local physicians in active practice who work closely with the Blue Cross medical directors and have input into coverage policy.

"We really do try to include the provider community in all medical management. It’s easy to do because we are decentralized and the local physicians have better rapport with the local offices," Wilson says.

The marketing team in the regional offices often calls on the case managers to talk to an employee group about the medical management program.

"I feel confident in saying that the case managers have sold many groups," she says.