A Guide for Medical Case Managers

The Guide is intended to assist medical case managers in gathering the critical information relevant to the individual claimant. These may be catastrophic medical cases which involve high dollar claims, long length of hospital stay and ongoing conditions. Failure to collect the appropriate information for these cases could result in large financial losses for the insurance carriers and will ensure appropriate care for the claimant.

The Guide is intended to assist medical case managers in gathering the critical information relevant to the individual claimant. These may be catastrophic medical cases which involve high dollar claims, long length of hospital stay and ongoing conditions. Failure to collect the appropriate information for these cases could result in large financial losses for the insurance carriers and will ensure appropriate care for the claimant. Lack of standardized data collection has made this process more cumbersome and financially risky. This Guide includes several sample intake, reporting and ongoing case management forms. This allows the case manager to more accurately project treatment and cost, going forward. These forms have been created from years of experience in the field.

Helen S. Philliou is the founder of Helen S. Philliou, Inc., a corporation that provides consulting services for: Case management oversight Large claim negotiation and review Assisting case management companies with reporting for reinsurers She works with clients throughout the United States. Her clients include: Managing general underwriters Third Party Administrators (TPA) Fully insured clients After doing hands on nursing care, she spent several years as a rehabilitation case manager (specialist) and then supervisor. Over time, she became responsible for large projects, like Workability, a work absence management program developed for Chrysler Corporation. Her ability to review and negotiate large claims led her to develop and implement a utilization review program for medical stop loss companies. She worked with their third party administrators and managing general underwriters and was responsible for reviewing and negotiating all hospital bills in excess of $50,000 that were out of network or out of area. She leverages her in depth knowledge of the medical claims environment to negotiate with hospitals, physicians, attorneys and other providers, such as home care and durable medical equipment (DME) vendors. She also serves as a resource to clients regarding case management issues and underwriters, regarding estimates of potential claims. She has developed trainings for nurses, to assist them in understanding the financial aspects of medical insurance. She is available to write and deliver training tailored to specific company needs.