A Guide for Medical Case Managers: Stop Loss Insurance for Medical Professionals

By Helen S. Philliou

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.

• Language: English
• Publisher: BookBaby
• Release date: Apr 11, 2023
• ISBN: 9781667897592

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Copyright © 2023 by Helen S. Philliou

All rights reserved.

No portion of this book may be reproduced in any form without written permission from the publisher or author, except as permitted by U.S. copyright law.

ISBN: 978-1-66-789759-2

Contents

Preface

1. What are the types of medical insurance available?

2. Referrals for Case Management

3. Information about the Claimant

4. Guides for Specialty Cases

Preterm Babies

Oncology

Traumatic Head Injury/Stroke

Chronic Renal Disease

Spinal Cord Injuries

Transplants

Car T cell therapy

Neonatal Babies

5. Mental Health

6. APPENDIX

Rancho Los Amigos Scale for Levels of Consciousness

Glascow Coma Scale

Categorization

Spinal Cord Assessment Tool

7. Glossary of terms

Benefit Plan Summary

Specific Stop Loss

Specific Deductible

Coordination of Benefits

COBRA

DRG

ERISA

Plan Document

TPA

About Author

Preface

Everyday case managers are asked to assess and review patients who have been referred to the case management program that employs them. Each day we are called upon to research new diagnoses, new medicines, and new treatment plans. Our nursing assessment levels range from the intensive care unit (ICU), medical/surgical units, rehab and outpatient therapy as well as home care needs.