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I still consider myself pretty new to the world of case managers, even though during any given week I usually talk to at least one. I never really understood what they were for exactly: to be helpful to the insurance company, or to us, or both? So even now, five years after being assigned our very first case manager just after my son’s autism diagnosis in 2011, I am still pretty clueless as to what their job description actually is.
We currently reside in CA, so we have United Healthcare Military and Veterans (UHCMV)…and their case managers. The first one that was assigned was awesome! She had all the answers and returned phone calls in a timely manner. If we needed or wanted something, it was taken care of. All was going great…until the changes to Autism coverage happened. When that change took effect, so did the change to our case manager. I called one day and she had been replaced with someone totally different. Initially, the new case manager was Ok, so I didn’t really think much of it, but recently, I have gone back to questioning her position.
Two months ago, I called the case manager to ask a question. Suddenly she was asking me a ton of questions that didn’t seem relevant to my call. Next thing I know, she’s requesting to conduct a “pediatric assessment” via the phone on the following day. This “assessment” lasted about an hour. We talked health, behavior, eating habits… you name it, she asked about it. When it was over, I was happy thinking I was in the clear. Boy was I wrong.
She started the conversation with, “I have to say…I’ve VERY concerned.” All I’m thinking was “concerned about what?? He’s healthy, happy; he gets his ABA therapy…what is there to question?” Apparently, a lot. The next thirty minutes of the call were a bit of a blur, but I do remember the tears I cried when the case manager told me she didn’t believe I was doing enough for my son. She then told me the steps I needed to take, which included calling my son’s PCM and asking for referrals for PT, OT, and Speech…which we didn’t want. After she was done bashing me, we got off the phone. I cried a little more and called my husband. My big question was, “can she force us to do this stuff?” After we discussed it, we decided to just not do anything. She was supposed to follow up in a month, so I would just deal with it then. Right? Wrong.
Last month I was speaking to the referral lady at my son’s doctor’s office about our ABA authorization. She told me it came through, and that she was working on those other referrals for me too. Then she got off the phone rather quickly. I thought it was a little strange that she mentioned “other” referrals since I hadn’t asked for any, but I let it go. Fast forward about a week. I brought the mail inside, and I noticed I had a ton of letters from United Healthcare. Opened the first…it was the auth for ABA. Perfect, great! Opened the next…it was an authorization for PT. Opened the next two, and both were authorizations for speech therapy. Opened the last…it was the decline letter for OT.
Once it all clicked, I became enraged. The next morning I called the PCM’s office, and to my surprise, they informed me that it was the case manager who had requested all of the unwanted referrals. She also told me that the case manager had spoken directly with my son’s doctor. I became even more furious. I speculate this is what happened: The case manager requested that I ask for these referrals. After a month of not having them come across her desk, she took it upon herself to call the doctor directly. So essentially she told the doctor exactly what she told me…that she didn’t believe I was doing enough for my son. Of course the doctor wants him to have all available services he’s entitled to and that will help him, so she put in the referrals, no questions asked. I immediately called my case manager’s supervisor…actually two of them. Like I said, I was furious. I ended up having to leave messages, but I felt a little better for the moment. I received a call back the following day. The supervisor was very apologetic and told me that in order to try to rectify the situation, she would like to assign me a new case manager. Perfect! She said it would take a couple of days to figure out who she’d like to set us up with. That was a week ago. I never heard anything else about it.
Here I am sitting and typing this actual blog when my phone rings. Caller ID says United Health. Silly me, I assumed it was the supervisor calling with the name of the new case manager. I was so wrong. Guess who?? None other than the original case manager herself. I instantly became irritated just hearing her voice. After confirming my identity and all that good stuff, she starts with, “ my supervisor told me you had some concerns, so I just wanted to call and follow up with you.” What?! Oh, I have concerns, but you were most definitely NOT supposed to call and follow up with me! So I opened my mouth, having no clue what was about to fall out. I actually ended up surprising myself. I was respectful, yet firm, and I voiced exactly how I felt about the situation. Her response was to talk over me, talk around my concerns, and generally treat me like an idiot. I also feel like she lied…and I don’t like liars. So after a calm exchange, we got off the phone. I immediately placed a call to her supervisor, because I felt that this was out of line, and I was officially done with her. I’m getting a new case manager!! Update: the supervisor called me the next day, and gave me the name and phone number of our new case manager! I’m a happy girl!
The moral of the story: there is no one size fits all when it comes to case managers. Some are wonderful, and really do believe it working together as a team. Others believe they know better than you, and take matters into their own hands. Whichever kind you get, don’t be afraid to speak your mind! I don’t need to tell any of you how to advocate for your child…you know them best. Do what works for your child and your family. If the case manager disagrees or gives you trouble, don’t be afraid to ask for another. After all, the most important thing is your child’s care.
Alissa Schuttpelz is a Coast Guard wife, and stay a home mom of two kids, ages 8, and 15. The family is currently stationed in Alameda, CA. Her 8-year-old son was diagnosed with moderate/severe autism in 2011. Since then, she has been trying to successfully navigate the sometimes complicated Tricare system. Along the way she has learned a lot of ins and outs, that she now tries to share with other people, especially those just starting out on their special needs journey.
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A site to discuss and learn about TRICARE Philippines Policies and Issues that are often times implemented in secret by the Defense Health Agency (DHA). Policies that result in payments at about 7.7% and 3.8% of what they should be or $328 per under 65 person instead of the expected $4,261 & $328 per over 65 person instead of the expected $8,650.
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