A delicate balance: CMs walk fine line between patients, payers

How to advocate for patients in a managed care era

America is experiencing a managed care backlash. More than 1,200 state-based managed care initiatives were proposed in 1997 alone. Five of the country's top 10 legal verdicts in 1995 were health care cases involving managed care. As consumers and legislators continue to attack managed care, case managers must remain true to their patient advocacy role to reduce liability and maintain quality patient care.

"Case managers should advocate for their client and the entire family. A patient is not just an individual, but part of a dynamic - parent, child, spouse," says Lynn S. Muller, RN, JD, CDMS, CCM, a partner with Muller & Muller in Bergenfield, NJ. "Illness and injury affect the entire family unit. You must hear what all those people have to say. This is the definition of advocacy."

What does it mean to be a good advocate? Several legal and case management experts offer case managers the following guidelines:

o Clarify language that is difficult to understand. "When someone is ill or injured, they receive a lot of paperwork. Help your client understand what those papers mean," Muller says.

o Research treatment options. "Case managers sometimes get criticized for looking for the cheapest, most effective ways to accomplish something," she says. "If I can get it cheaper with no fewer benefits, what's wrong with that? Isn't that what being a good consumer is all about? We still live in a country driven by competition and capitalism. If you can get the same service and achieve the same goal for less money, stop apologizing for it."

From generalists to specialists

"Advocacy is not an open door," cautions Mark O, Hiepler, JD, a partner with Hiepler and Hiepler in Oxnard, CA. "Part of your role involves counseling. You don't have to provide three wheelchairs when one will do."

Others agree. "Many patients have an entitlement mentality," notes Larry Chapman, BS, MT, MPH, chairman and senior consultant for Summex in Seattle. "Case managers must add an element of discipline and shared responsibility on the part of their clients."

To be effective advocates, case managers also must remain current with advances in medical treatment. "We must know what clients expect from us in terms of the newest technology. It's a huge challenge case managers face today," says Deborah S. Smith, MN, RN, CNAA, executive vice president of American Medical Systems in Los Angeles. "One of the most important things we can do is recognize what we need to know."

When patients hear about new treatment options, the case manager often gets "stuck in the middle," says Marlys S. Severson, RN, BSN, CCM, president and chief executive officer of SCM Associates in Cypress, CA, and past president of the Case Management Society of America in Little Rock, AR. "I feel that the treatment of such conditions as AIDS has become so complicated that case managers may find themselves moving from being generalists to being specialists. My own staff is specialized internally."

o Listen to all concerned parties. "The hardest and most important thing an advocate must do is listen," Muller says. "Hear what your client needs and wants, Whether in your initial telephone conversation or in a face-to-face interview, ask the client and the family what they need to get out of this relationship."

o Maintain a constant dialogue. "You are spending someone else's money," Muller says. "You have an obligation to constantly check to make sure you are getting them what they want. Make sure you understand clearly all the client's issues. Ask yourself what the important issues that need to be addressed are."

o Represent yourself honestly. "To be an effective advocate, you must be honest with your clients," she says. "Make sure your client understands that you represent the payer source. Tell your client clearly that you are collecting information that will be shared with the payer. Repeat that message often, if necessary."

o Review all the medical records. "You should also look at the whole client. Look at their lifestyle before you make decisions. You can't make appropriate decisions for someone else without understanding who they are. Case managers get to spend other people's money and decide what's appropriate for them. Would you feel comfortable having someone decide what's right for you?" Muller asks.

o Understand the covered benefits. "Case managers deal with many health plans. It's important to have someone from the health plan or medical group explain to you what is covered and what is not," Hiepler says. "You're off the hook in terms of liability if you can say that you can't advocate for benefits that aren't covered."

o Seek internal solutions to conflicts. If you are an in-house case manager for an insurance company, and you know the company is acting in bad faith, it's possible for you to advocate for your patient without losing your job, Muller says.

"Go up the chain of command. Let people know you are uncomfortable and identify the issues for those above you the chain. And, of course, document your concerns and that you reported them to someone. Sometimes, simply reporting the issues and documenting that you reported them is the best you can do," she says.

"Remember you are in a fiduciary position to the patient but still obligated to your health plan employer," Hiepler says. "The safest thing to do is to ask the medical director for a peer review discussion. Peer review discussions are confidential and protected from discovery in a lawsuit. By requesting a medical peer review, you advocate for your patient, while at the same time showing your employer that you are trying to keep the dispute within protected confines."

Your best defense: Honesty

In addition, Hiepler recommends that case managers ask someone to accompany them to the medical peer review. "During the review, explain clearly what's going on and what you think needs to be done differently. If your request for a medical peer review is denied, request a meeting with the chief executive officer.

"If that fails, go to your company's legal counsel. The legal counsel may be your greatest help in these situations. The legal counsel not only understands the liability involved, but has an interest in solving the problem before it escalates," he says.

Of course, if even your company's legal counsel fails to help you resolve your patient's conflict, you can turn to the insurance commissioner in your state, Hiepler says. "At that point, however, your job is at risk."

At the end of the day, Muller says the case manager's best defense and greatest peace of mind will come down to the following three statements:

o I informed my client clearly.

o I didn't misrepresent anything I was going to say or do.

o I did the best, most cost-effective job to serve the person who hired me.