Jump to content

Do you want up to date information about Scleroderma? Check out our Medical pages at www.sclero.org for all your Scleroderma questions!


Received a letter from health insurance company

  • Please log in to reply
8 replies to this topic

#1 enjoytheride


    Senior Silver Member

  • Members
  • PipPipPipPipPip
  • 367 posts

Posted 15 January 2011 - 01:56 PM

I just got a letter from my health insurance co saying I may qualify for free (in caps) personal health care support system. It is a contracted service to provide "program nurses" to work with my physicians to support my "treatment plan." They offer a nurse case manager in an "effort to obtain the best possible care." Specially trained nurses are available 24-7. The letter asks me to contact them and says that if I don't a nurse will be in touch with me.
A form to fill out to "enroll" was enclosed. The letter lists some conditions that qualify for this service which includes scleroderma.
I don't know whether this is a good thing (I would love to have some tell me what's what) or a bad thing (is the point to interfere with expensive treatment.)
Anyone involved in something like this?
I have a real problem in that I have a very good internist as my primary physician but he is in a group that includes the rheumatologist I see (I find her very unhelpful) and the gastroenterologist (who I also like.) It would be good to get more information on stuff but are they supporting the insurance company or me? I will ask my primary doctor what he thinks before I sign up no matter what- he is a sort of authoritarian type doctor but has been better than any I've seen in years.

#2 Jeannie McClelland

Jeannie McClelland

    Senior Gold Member

  • ISN Support Specialists
  • PipPipPipPipPipPipPipPipPipPip
  • 1,706 posts
  • Location:in the Rocky Mountains of the USA

Posted 15 January 2011 - 04:18 PM

I've gotten these 'offers' several times in the last few years and have never replied. The first one, when the nurse called, she said they could educate me and help treat my asthma. I told her I didn't have asthma, so no thanks. The last several haven't mentioned a condition, but I've still declined. I like and trust all my doctors, don't want someone working for the insurance company meddling in any way, and frankly, don't see what they could offer that I would want to participate in. As my mother-in-law always used to say, even paranoids have enemies. <_<

The most recent event was a booklet from the company that makes the pulmonary hypertension drug I am on giving me info on how to argue with the insurance companies and/or Medicare/Medicate to get them to cover the drug AND appointing a case manager for me to liaise with. Do they know something I don't? Very alarming, to say the least.
Jeannie McClelland
(Retired) ISN Director of Support Services
(Retired) ISN Sclero Forums Manager
(Retired) ISN Blog Manager
(Retired) ISN Assistant News Guide
(Retired) ISN Artist
International Scleroderma Network

#3 CraigR


    Senior Silver Member

  • Members
  • PipPipPipPipPip
  • 438 posts
  • Location:Escondido (near San Diego), Ca

Posted 15 January 2011 - 05:48 PM

I've gotten various offers. There's some sort of "medical coaching" or help through the insurance company. They basically seem to indicate that they are there to answer questions. I haven't used them. They sound very basic - would probably tell me to keep my hands warm (duh...).

On one occasion I got a call to help me with my "congestive heart failure", which I don't have. They probably drew a false conclusion from pulmonary hypertension.

They don't seem sneaky - but seemed meant more for patients who aren't researching common conditions.

When we consider the importance of finding an expert, and how few doctors have experience with this disease, it seems unlikely that a telephone nurse would have anything to offer. At least that's how it seems to me...


#4 Robyn Sims

Robyn Sims

    Silver Member

  • Members
  • PipPipPipPip
  • 166 posts
  • Location:Melbourne Australia

Posted 16 January 2011 - 12:28 AM


Reading your posts makes me realise how lucky we are here in Australia to have a "free" medical system.

Our members can go to an expert scleroderma specialist at a public hospital with no out-of-pocket expenses. The hard part is finding the right "expert".

Recently my daughter visited the emergency department of a large hospital in the western suburbs of Melbourne. The young doctor recognised immediately that she had scleroderma and the nurse on duty, without asking, offered her an extra blanket! They took into account all her special needs.

Scleroderma Victoria helps fund two scleroderma specialty clinical nurses at two scleroderma clincis who are available on the phone or for visits regarding wound care and other issues. We feel that this is a great way of supporting our members. They also ensure that when a patient visits their doctor that all appointments for tests, ie lung function, scans, bone density, are arranged for the same day. It certainly goes a long way to helping with stress.

When reading some of your posts I can see that your medical system can be very hard for those with a chronic disease.

Kind regards,


#5 jillatk


    Senior Bronze Member

  • Members
  • PipPipPip
  • 78 posts
  • Location:Colorado

Posted 16 January 2011 - 05:12 AM

I once ended up with one of those nurses after a trip to the emergency room with an asthma attack (pre scleroderma). The nurse would call me and want my peak flow number's and whether I was compliant with my medication regime. I asked her if she could help me get through the system and get a pneumonia vaccination and she said she was unable to help me with that. So I then asked her what her purpose was if she was unable to help me get what I need to prevent another trip to the E.R. That was the end of that service. It was pretty benign and useless as far as I could see.

I assume I got a nurse case manager in response to the very unusual event of an asthma attack. I guess they are there just to keep track of you in an attempt to reduce costly interventions such as the E.R. I probably got a black mark against my name when I opted out. Like others here I am doubtful it would be a helpful service if you already have good care.


#6 enjoytheride


    Senior Silver Member

  • Topic Starter
  • Members
  • PipPipPipPipPip
  • 367 posts

Posted 16 January 2011 - 05:20 AM

Hi Robyn- I feel lucky with my health insurance too. I do not need a referral as I can go to whoever will take me at my own choice. It would be nice to have no expense with this but at least I have a choice. And I can usually get an appointment with my doctor within a day or two- they will work me in immediately if it's urgent.
My issue with the original post is whether this "service" will be a help or a hinderance to getting the care I need. I'm still hoping to hear from someone who has used it- so far most people seemed to have been cautious in using this sort of thing.

#7 janey


    Platinum Member

  • ISN Support Specialists
  • PipPipPipPipPipPipPipPipPipPip
  • 2,118 posts
  • Location:New Mexico

Posted 16 January 2011 - 09:45 AM

Well, I must be one of the few that have actually had success in such a program. I wasn't really given a choice, but that's o.k. because it's been invaluable. When I was hospitalized a few years ago a nurse contacted my husband and said that she was the case manager/nursing consult for my insurance. Since I was totally out of it and I had always been the one that dealt with insurance issues, my husband was at a lost. The nurse helped my husband in dealing with the doctors and the hospital and then once I got out of the hospital, in dealing with the bills that started coming in - none of which I had to pay - and SHE took care of it. Recently, my insurance company sent a letter saying they "preferred" a certain company to handle my IVIg infusions. I contacted my case manager and he (a new one) patiently listened to my concerns of switching to a new clinic after using the same one for over 6 years and with a lot of success. He worked with my rheumatologist, the "new IVIg provider" and the insurance company to set up a system where my rheumatologist purchases the medication directly from the new provider and they ship the IVIg directly to my current infusion clinic. This eliminated the middle man (thus less costs to the insurance company and the rheumatologist it turns out) and allowed me to stay at my current clinic. There have been a couple of other issues in which my case manager has been helpful, so for me - this process has been invaluable!

I just posted an article on the success of Team-based treatment for chronically ill patients like us, so be sure to take a look at it. It might provide you some information as well.
Janey Willis
ISN Support Specialist
(Retired) ISN Assistant Webmaster
(Retired) ISN News Director
(Retired) ISN Technical Writer for Training Manuals
International Scleroderma Network (ISN)

#8 enjoytheride


    Senior Silver Member

  • Topic Starter
  • Members
  • PipPipPipPipPip
  • 367 posts

Posted 16 January 2011 - 01:42 PM

Thank you Jillak and Janey- it is good to have some idea of what I can expect. At least it doesn't seem like it causes a problem with the doctor, which worried me.

#9 Shelley Ensz

Shelley Ensz

    Root Administrator

  • ISN Root Admin
  • PipPipPipPipPipPipPipPipPipPipPipPip
  • 3,263 posts
  • Location:Minnesota

Posted 17 January 2011 - 07:18 AM

Hi Enjoy,

Will you let us know what becomes of this, and whether you find the service helpful, or not?

I haven't had any offers like this, but my health insurance company has a nurse's hotline which I find very helpful. They are great on advising how serious symptoms are, whether I should go to ER or self-treat or go to the doctor, and so on. Especially with chronic illness, sometimes there's quite a quandary as to how soon you need to be seen for certain things, or which doctor or specialist to consult about it first. This sounds very different from what you are describing, though. So I'm curious as to how it turns out for you.
Warm Hugs,

Shelley Ensz
Founder and President
International Scleroderma Network (ISN)
Hotline and Donations: 1-800-564-7099

The most important thing in the world to know about scleroderma is sclero.org.