Jan Gambino Jan Gambino's Blog

Do you need a Medical Insurance Case Manager?

It can be very time consuming and confusing to navigate the medical care system when you have a sick child. There are doctor’s appointments to schedule, prescription medications to pick up at the pharmacy and referrals and pre authorizations to obtain. Not to mention the never ending cycle of home care: feeding, bathing, cleaning, comforting and all the rest. Juggling all of the caretaking demands can really test your endurance. A small frustration such as waiting on hold or getting cut off (after waiting on hold) can really be the last straw when you are already stressed and worn out. Imagine if you didn’t have to go through so many hoops? A case manager works for the insurance company and helps you access the services you need that are covered by the plan.

Some of the bigger insurance companies will only provide a case manager to a patient with a complex or chronic health issue such as cancer or diabetes. While there isn’t widespread use of a medical case manager for refluxers, a child with multiple medical issues such as severe asthma, tube feeding or serious feeding aversion may qualify for this service as well as a child with special needs such as developmental delay or prematurity. For instance, a premature infant may have a case manager assigned to arrange home care and follow up before being discharged from the hospital with an apnea monitor, home oxygen and tube feeding. It might be worthwhile to contact the insurance company and ask to be assigned to a medical case manager.

The case manager can assist caretakers in obtaining specialized services such as home delivery of prescriptions, home care equipment and authorization for therapy or feeding programs that are covered by the insurance company. The case manager may have to contact the physician, obtain reports and submit other information to get authorization for an in-patient feeding clinic, especially if it is out of state. Often the case manager can save the caretaker a great deal of time and effort by working on your behalf to get authorization for services and quicken the pace of approval. You let the case manager make all of the calls while you tend to your child. What could be better?

A medical case manager was able to help an American family in need when their infant daughter was born prematurely in Central America. Her parents flew back and forth to see her as much as possible. The medical system was entirely different and it was difficult to coordinate her care with doctors who spoke very little English. The doctors were pressuring the family to perform a surgical procedure for reflux and they didn’t know if this was the best treatment plan for their daughter. They really wanted to have their baby transferred to a hospital in the United States but that seemed impossible. I encouraged the parents to contact their insurance company to see if a medical case manager could assist them. A case manager was assigned to the case and within a short period of time, the baby was airlifted to a hospital in the United States. She made steady progress in the hospital and did not need surgery. Best of all, her family could stay in a nearby Ronald McDonald House and visit their baby every day. Perhaps having her parents by her side was all she needed!

While calling the insurance company requires yet another phone call, navigating the phone menu options and perhaps losing the connection, I hope you end up with a case manager on the line. You benefit from having assistance in obtaining the services you need. The insurance company wins too - by providing prompt, specialized care, your child will have a positive outcome and perhaps will not need expensive long term care.


Check with your
doctor first!