The Role(s) of the Complex Care Case Manager

Myers: Part of our role is to help dealing with the insurance companies, getting certain treatments or services approved. We’re the go between dealing with the insurance company, finding out from the doctor what they want to do with the patient as far as their treatment plan, and then we deal with the insurance company about trying to get that approved. We deal with Medi-Cal; we deal with Medicare; we deal with private insurances; we deal with Worker’s Comp; we deal with the veterans insurance, TriCare. We’re pretty much advocating for the patient with the insurance company, finding out what’s covered, pushing for something to get covered if they say they don’t usually, and there’re different negotiations we can do as far as getting the treatment the patient needs by working with the insurance company.

Sugarman: We also work with the patient, helping them understand what their insurance covers and will cover, and this comes up a lot when we’re assisting patients in getting connected with mental health resources. We will help them understand their benefit in terms of what levels of care they’re able to receive, how many sessions… like the physical therapy form with Medicare, how many Medicare sessions they can have and use, and where they can go through Medicare—so really helping patients to understand their insurance benefit and know how to navigate it.