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Healthy Savings
Many corporate clients are demanding a more sophisticated approach to case management. Sam Barrett finds out more
September 2007 Features
Case management can help an insurer keep a lid on rising claims costs as well as support customers during a claim. But, while every insurer is keen to promote its ability to contain costs through case management, there are a number of different interpretations of what it actually entails.
Probably the biggest exponent of case management is CIGNA HealthCare. It introduced the concept to the UK in the early 1990s and uses it across all its medical insurance business.
“It’s at the heart of what we do,” says Ann Dougan, marketing director at CIGNA HealthCare. “It’s designed to look after the employee while helping to manage the costs. From an employer’s perspective this means cost control as well as employee satisfaction.”
To enable this, every call relating to a claim is answered by a case management nurse, who assesses its nature and provides support and guidance where necessary.
For routine claims, such as a tonsillectomy or cataract removal, the nurse will ensure the treatment plan is in line with best practice, checking areas such as cost and length of stay. Additionally they might provide information about the operation to the claimant, helping to reassure them about the treatment.
“If there’s a query over the treatment plan the nurse will speak to the consultant or hospital, although generally this isn’t necessary with routine claims,” explains Dougan.
More complex cases require a much more hands-on approach.
“We have a multi-disciplinary team for the really complex conditions such as cancer, cardiac conditions, psychiatric and major trauma,” adds Dougan. “They’re trained to provide support through the claim.”
Other interested parties such as relatives and employers might also be involved, subject to authorisation from the claimant. In some cases, the nurse might also recommend specialist support from other parties such as charities or benefits agencies.
The case management nurse will also speak to the consultant and hospital to ensure the treatment plan is appropriate and, where benefit may be limited, to optimise cover. For instance, if a case could be treated in the NHS, it might be possible to use the benefit that is saved to provide other support such as childcare or rehabilitation.
A further advantage of this extensive form of case management is its ability to integrate other healthcare services. For instance, Dougan says the case management nurses have details of other services offered by the employer and will refer callers to these where appropriate.
So, if someone calls in with a claim for counselling for stress, the nurse could refer them to the employee assistance programme, or if the claim was for a lifestyle related condition, for instance a bad back caused by being overweight, they might refer them to the diet and exercise section of the wellbeing programme.
“It allows a wider view of your healthcare benefits,” adds Dougan. “Rather than treating it as a healthcare claim it allows a company to enjoy a more integrated application of its benefits.”
Other insurers have also adopted case management, although on a more limited scale. Paul Richardson, standards manager at Standard Life Healthcare, explains: “We don’t manage every single case but will involve case management for the more serious, life-threatening cases where it will benefit the customer. It helps to make sure they get the right level of benefit and it’s also good that they have a named individual they can talk to throughout their treatment.”
He adds that where a corporate client would like more case management this can be included in the scheme.
A similar approach is taken at
“We do this to support the customer and ensure there aren’t any shocks during their treatment but it can have a financial benefit too,” he explains. “We don’t believe it’s necessary for smaller claims as it introduces additional cost that won’t be recouped.”
It’s not only the insurers that provide case management services to their medial insurance clients. Third party administrators also offer case management services, especially for companies running medical expenses trusts.
“It’s even more important to manage expenditure when it’s a self-funded scheme,” says John Picken, chief executive at Medisure.
It has been running a case management service for many years and links it to a range of liability products, including employer’s liability, motor insurance and group income protection. Like CIGNA HealthCare, every claim is notified to the case management helpdesk.
“We agree protocols with each client,” adds Picken. “Some want everything to be managed and use the management information to identify trends in their business; others prefer a softer touch.”
Some of the larger intermediaries also run case management services. Some provide an initial helpline to provide support on making a claim; others run a full case management service with nurses dealing with claims.
The PMI Health Group falls into this latter category. It set up its case management service in 1992 and now employs 10 nurses to look after roughly 120,000 lives.
“Every claim is dealt with through our case management nurses and each company has a dedicated nurse so all its claims are dealt with by the same person,” explains Steve Langan, group sales director at PMI Health Group.
There is an additional cost for this service with employers paying between £36 and £40 a year for every employee covered. However, Langan says that this generates an average saving of £2.40 for every £1 spent.
“It varies hugely though depending on the age and claims profile as well as how hard or soft the employer want us to manage claims,” Langan adds. “We don’t make any huge promises about cutting costs when we’re engaged as the service is intended to support the employee as much as save money.”
Large, complex cases are where the bulk of the savings come. Treatment for conditions such as cancer and cardiac problems is traditionally delivered very well within the NHS so managing a claim into the NHS can save substantial amounts.
Significant cost savings can also be made on psychiatric claims because of the wide variation in treatment. When faced with these types of claims, case management nurses would look to promote short courses of treatment or outpatient rather than long courses of inpatient treatment.
With the intermediary-run services there is clearly some duplication with the service offered by insurers. However, in most cases, the insurers are happy to work alongside the intermediaries’ case management services.
Indeed, in some cases it can work particularly well for the insurer, as Sclare explains: “The intermediary is independent so will be in a better position to support the customer, especially where they might be better being treated within the NHS. It’s not easy for an insurer to push a customer towards the NHS, even when it’s a better option.”
Case study
Suffering from complications that affected his breathing, this baby boy was admitted to the special care baby unit within the local NHS hospital. His father called CIGNA HealthCare’s nurse helpline for advice and the nurse explained the various ways in which the benefits on his plan could be used. These included cash benefit for using the NHS and the care coordination programme that allows members more flexibility around how their benefits are used.
The nurse also explained that although there were private facilities available, this might not be the best option as sick babies are best cared for within the dedicated intensive care units within the NHS.
The baby’s doctor agreed with the nurse’s recommendation and the baby stayed in the NHS hospital making a full recovery and enabling the family to claim NHS cash benefit. Further, the management of the case saved around £20,000.
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