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Acute care providers sometimes think of case managers from insurance companies as hard-hearted tightwads who are more interested in saving money than saving the patient. On the other hand, insurance case managers may see their counterparts on the provider side as spendthrifts who want to pour more money into a patient’s care even if they aren’t sure the intervention will work.
An antagonistic relationship doesn’t help anyone, says Toni Cesta, PhD, RN, FAAN, director of case management at St. Vincent Hospital in New York City. That’s why case managers in all aspects of health care need to communicate and collaborate on creating the most effective and cost-effective plan of care for the patient.
The relationship between payer case managers and providers doesn’t have to be adversarial, says Alan Cudney, RN, MBA, MHS, CPHQ, CHE, an associate with Premier Inc. in Charlotte, NC. "Physicians who work with a true case manager who is trying to empower them instead of manage them, tend to be delighted with the results," Cudney adds.
Here are some tips from both sides of the fence on how payer case managers and acute care providers can better work together:
• Stay calm, cool, and collected as you collaborate. Bad attitudes and animosity don’t help anyone, least of all the patient.
• Share your case management plan with the other case managers on the case.
• Be cognizant of time constraints and speed up your responses to providers when you’re dealing with a situation that needs a timely response. "Sometimes [payer-based] case managers block us from getting to the medical director, or the medical director doesn’t respond and we’re dealing with a window of hours," Cesta says.
• Understand that clinical credibility is the key to having a good relationship with providers. Make sure that whoever fields your telephone calls knows what he or she is talking about. "When someone asks us how to spell common medications, that gives us a sense that we are working with someone who is not able to make a credible decision about what care a patient does or does not need," Cesta says.
• Make sure your case management team is understanding and willing to work with providers for the patient’s benefit. "When people come at it with a bureaucratic approach and no discussion or negotiation, it’s a problem," Cesta says.
• If you’re a provider, don’t be afraid to have case managers actually visit your site. "If the care processes are what you want them to be, it’s a perfect chance to show them that the person is really sick," Cesta says.