The Heart of Care: "Detective Work" Helps Child Get Vision-Saving Services

September 17, 2019

Melissa Al-Ahmadi, a licensed master social worker and Evolent Health Care Advisor, wears several hats when it comes to helping her patients: care coordinator, health coach and patient advocate. But her dedication doesn’t stop there. In one recent case she embraced a new role—more like a detective getting to the bottom of a patient's frustrating problems.

Melissa was working with "Michael," a boy at risk of losing his eyesight due to a rare disease. Although there were no physicians in network who had the expertise to treat him, requests to see an out-of-network specialist were repeatedly denied. Why was this happening? Melissa was on the case to find a solution for Michael and his vision.

Michael has neurotrophic keratitis, a chronic condition that makes him unable to produce the basal tears that keep eyes lubricated and protect them against irritants, such as dust. Without continued treatment, the corneas can dry out, leading to blindness.

Several years earlier, with financial support from a grant, Michael had undergone a procedure called PROSE—prosthetic replacement of the ocular surface ecosystem—to help preserve his vision. In the surgery, a custom-designed device, almost like a contact lens, is implanted to help perform the functions that Michael's eyes could not do on their own. However, the surgery is not a permanent fix. Michael needed continued follow-up visits with specialists—not covered by the grant—to treat his neurotrophic keratitis and assess the status and fittings of the PROSE prosthetics. As he grew, he would need replacement prosthetics.

That’s where Michael’s care was hitting roadblocks. For more than a year before Melissa took the case, Michael's mother had been unable to get approval for these out-of-network specialists. He became legally blind, and he needed to undergo three corrective surgeries (covered by the grant) to remove cloudiness from the cornea. While these procedures helped, they did not address the long-term risk of vision loss. His mother was concerned about his care, its financial toll, and the prospect of even more corrective surgeries.

"This is what really motivated me to go that extra mile," Melissa recalls.

Over the next two weeks, Melissa spent time on the phone with Michael's mother, several physician offices (both primary and specialty care), the health plan's utilization management department and the Evolent market team to get to the bottom of Michael's out-of-network denials. After diligent note-taking, research and close contact with her Evolent manager, Melissa was able to pinpoint the reason for the denials. Astoundingly, it amounted to just a few numbers in a diagnosis code: The primary care office had been submitting documentation for Michael that used the code for keratitis, a temporary inflammation of the cornea that can often be treated with eye drops. There were many ophthalmologists in network who could treat keratitis. However, none were experienced in Michael's disease, neurotrophic keratitis.

With Melissa's help, the primary care provider submitted the correct out-of-network referral with Michael's diagnosis code. The referral was approved, and Michael was able to schedule appointments with the specialists who could properly manage his disease.

He and his mother were very grateful for her speedy resolution and diligence, especially knowing that time was of the essence for Michael and his eyesight. Without Melissa's help, Michael may have needed to undergo several more painful, expensive and potentially unnecessary surgeries to help avoid vision loss.

About The Heart of Care
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.

 

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