When patients are denied authorization for a piece of medical equipment, it can be more than frustrating. Sometimes, it can be life-threatening.
That reality weighed on RN Care Advisor Andrea Baker as she reviewed the case file of "Austin," a young patient who had returned home from the hospital the previous day. Respiratory illness season was around the corner, and the boy was highly vulnerable—he had a history of heart problems and asthma and relied on a breathing tube. To reduce his risk, Austin's medical team had sent him home with a percussion vest, which loosens and removes secretions that can contribute to infection.
Yet Andrea found an unwelcome surprise in the chart: a Utilization Management nurse had entered a note denying authorization for continued use of the percussion vest. Andrea was puzzled because the boy had seemed like a perfect candidate.
Andrea helps to coordinate the care of pediatric Medicaid recipients while educating them and their family members on how to manage their health challenges. But she also spends time overcoming bureaucratic barriers and plugging gaps in the health care system—tasks like reversing incorrect denials. She brings both personal and professional experience to the task.
"Being a special needs parent myself, I would be blindsided when I would deal with these kinds of challenges," Andrea says. "Their lives have been turned upside-down, but they're hitting walls in terms of getting their kids what they need."
Fearing that Austin could lose the vest—even if it was just for a week while an appeal played out—Andrea made a flurry of contacts to quickly resolve the issue. She started by calling a representative from the durable medical equipment (DME) provider that supplied the vest. The rep told Andrea that authorization had been denied because the patient had not complied with a requirement for follow-up visits with a pulmonologist.
Andrea knew that wasn't true. A month earlier she had joined Austin and his mother at the lung specialist's office. For some reason the record of that visit had not reached the insurer.
She then gave the DME representative the direct phone number of the nurse in the pulmonology office, so the nurse could fax the note for Austin's most recent visit. Andrea also contacted a nurse in Utilization Management who had just entered the denial note to let her know to expect a call from the DME rep, who would be sending new clinical data.
Not leaving anything to chance, Andrea then called and messaged the nurse in the pulmonologist's office to make sure she understood the situation. Within about two hours, Utilization Management responded, stating that it had received the clinical details it needed from the pulmonologist visit, voided the denial note and approved Austin’s vest.
Andrea is thankful she was reviewing the file when she did, and that she had first-hand knowledge of the child's pulmonology visit. Austin's family, who was already overwhelmed with the duties of caring for a fragile child at home, wasn't aware of the initial denial and was spared from worrying about one more problem. Andrea had done all the work behind the scenes.
She understands that, for her patients to do well, their parents need as much help as she can give them. So, Andrea shares what she learned along her own journey.
"I know how hard it is to work and to get your kid to therapy appointments and follow-up specialist appointments," she says. "It's a job in itself. I tell them: I've been in your shoes."
Every day, members of Evolent's care management teams use their clinical expertise and problem-solving skills to help individuals overcome serious health challenges. The Heart of Care series tells stories from the field that highlight their dedication to patients. For more information, see the blog post by Evolent CEO Frank Williams.