MA Case Management Program

The Medicare Advantage Case Management Program is a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates options and services required to meet member’s health needs and to promote quality and cost-effective interventions and outcomes across the continuum of care. A nurse will work with members, their families, their doctor and other health professionals to facilitate appropriate utilization of health care services, and to help members reach their optimum level of wellness through education, support and coordination of care. Blue Cross and Blue Shield of Nebraska (BCBSNE) annually reviews and updates the CM program.  

The primary goals of the Medicare Advantage Case Management Program are to:

• Reduce costs related to unplanned readmissions, optimize resource utilization, affect healthy outcomes and member experience and support efforts for measures and STARS rating.  
• Help members manage complex and chronic health conditions.  
• Decrease the burden of disease complications through referrals to improve member self-management, increase member compliance with treatment plans to maximize quality of life and reduce risk of unnecessary utilization.

The Case Manager Role  
A Medical Management case manager facilitates the physician’s plan of treatment and the provision of health care services as outlined in evidence-based clinical practice guidelines. The case manager contacts members by phone to perform an assessment of the member’s health care status. Goals are identified and interventions are implemented to support the physician’s treatment plan. The case manager provides personalized support and education on disease, nutrition, medication and managed care processes and also identifies and facilitates access to benefits and resources available to prevent complications and progression of disease.  

The case manager coordinates care with the treating physician and offers suggestions to practitioners for member management. Timely communication with the treating practitioner is essential in the performance of case management activities. Ongoing communication occurs based on changes in the member’s condition or identified needs.  

The case manager may contact the treating practitioner, and talk with the plan medical director, as necessary, in the following circumstances:  

• When there are significant changes in the member’s health status 
• When intervention on the part of the treating practitioner is thought to be necessary  
• When the member uses emergency room services or is admitted for inpatient care  
• To review the member’s progress at various intervals in the case management process  
• To notify the treating practitioner that:  
  • A member who was participating in the case management program but who refuses further intervention even though goals are unmet  
  • A member has not complied with the recommended plan of care  
  • A potential urgent or emergent situation has been identified related to a member (for example, safety issues such as a member self-reporting that they took an unusually large dose of medication or the case manager identifying a potential case of abuse or neglect)  
  • To obtain the health information necessary to ensure the highest quality of care  

The Medical Management program provides patient-focused, individualized case management for members who meet trigger criteria, including but not limited to the following:

• Are dealing with chronic or complex disease process 
• Are at high risk for health complications 
• Demonstrate high use of health care resources 
• Experience admissions and readmissions to an inpatient care setting 
• Have gaps in medical care 
• Have medication compliance issues

Case Management Direct Referral Sources  
Typical referral sources may include (but are not limited to):  

• Customer Service 
• Care Transition program 
• Primary Care Physician 
• Completion of health assessments 
• UM inpatient admissions 
• Members and caregivers 

Conditions Addressed by Case Management Services  
Case management services are available for members with the following conditions (but are not limited to): 

• Chronic obstructive pulmonary disease 
• Complex conditions 
• Diabetes 
• Heart failure 
• High-risk pregnancy 
• Ischemic heart disease 
• Kidney health management 
• Oncology 

What Physicians can Expect from Case Management  
Case managers recognize the provider’s right to:  

• Obtain information about case management programs and staff, including staff qualifications, with which the provider’s members are involved
• Be informed about coordination of case management activities, interventions and treatment plans through reports from the case manager throughout the course of case management 
• Be supported by the case manager in making decisions interactively with members regarding member health care needs 
• Receive courteous and respectful treatment from the case management staff 
• Know how to contact the person responsible for managing and communicating with the provider’s patients 

Note: Case managers may receive requests for services specifically excluded from the member’s benefit package and will not make exceptions to member benefits, which are defined by the limits and exclusions outlined by the individual member’s certificate and riders. In these situations, case managers inform the member about alternative resources for continuing care and how to obtain care, as appropriate, when a service is not covered or when coverage ends.