When it comes to managing high cost claims, a unique set of considerations can make navigating the process challenging. Beyond cost containment, medical case management is essential and doesn’t stop when treatment terminates. “Managing catastrophic medical claims takes a highly coordinated effort, one that is monitored along the continuum of care even after treatment, to be effective,” confirmed Gitte Bach, President and CEO, New Frontier Group. Indeed, all stakeholders working together from beginning to end ensures a seamless process and this begins with identifying patient needs.

Faz Subhani, Head of International Business at Penfield Medical Cost Containment Inc., added: “As a specialist in case management and cost containment business in North America, we feel strongly that early intervention is critical, particularly in the profit-driven US healthcare system. The advantages of early intervention and directional care are two-fold, determining both the quality of care the patient will receive, as well as controlling and managing the financial cost to our client.”

The patient comes first
Dr Cai Glushak, Medical Director, AXA Partners, said that, first and foremost, understanding the specifics of the medical situation and the capability of the local structure to handle it is crucial, as meeting patient needs is the primary consideration: “This is to rapidly establish whether the patient is having their essential needs met or should be moved to a higher level of care,” he told ITIJ. He provided an insight into how AXA Partners goes about this: “We do this by obtaining medical information by any means possible in the fastest way – for example, a direct call to provider, information from family or companions present or local correspondents, as well as using our extensive database on provider capabilities. All this is primed by our rating system for country and locality healthcare capabilities that immediately alerts all staff as to the general level of risk for the location of the patient.”

Bach agreed with the importance of patient care and how this is boosted with diverse, high-level clinical expertise: “A variety of medical experts are needed based on the specific case to understand the condition and available treatment options for the patient. Ensuring the patient is receiving high-quality care and has access to everything they need to continue treatment is essential to assure the best outcomes.”

“Patient safety is paramount,” added Subhani, “and when directing insureds to a hospital in the USA for emergency care, choosing the highest quality facility available provides a number of benefits both for the patient and Penfield’s clients. The higher quality facilities will be less prone to medical errors (which can prolong an admission and cause costs to rise). They also tend to provide more streamlined, efficient care protocols and have access to the very latest medical equipment. This efficiency should enable an earlier discharge back to the patient’s home, and manage overall costs.”

Monica Rummelhoff, Executive Director, GMMI, Inc., also confirmed that patient needs consistently come first: “The number one consideration is always the patients’ needs and providing a safe and successful outcome,” she told ITIJ. “These are typically high stakes situations, so our focus is on stabilising the patient, moving quickly, and getting the patient to the best facility in our network to maximise the coverage for the situation at hand for treatment.”

Rummelhoff underlined the need for continuous monitoring of the case and communication with loved ones. “Throughout treatment, it is important for us to continuously monitor the case so we can make sure that the care the patient is receiving is the right care for them. After receiving informed consent from the member, we can assist in keeping their loved ones aware, aligned, and informed of the healthcare elated decisions that are taking place.”

Dr Glushak said that continuous monitoring ensures care delivery remains pertinent and affords the opportunity to decide on the appropriate time to repatriate the patient or change the care being delivered: “Once we are satisfied we have ensured the patient is getting the level of care they need, we continuously monitor the care to determine medical necessity, not just at the outset, but at all stages of care along the way. We watch carefully for medical windows of opportunity to return the patient to their home medical system, especially where local costs are high. Alternatively, we look for opportunities to propose alternative cost-effective care options, such as outpatient rehab or home care until the patient is fit to fly home in some manner.”

Subhani said: “Case management is the front line for cost containment – and Penfield’s goal is to begin care management (and therefore cost controls) from the first call, ensuring that only necessary care is approved and delivered.  Having a full record from first call also allows services to be adjudicated post-treatment, and non-approved and/or unnecessary care may not be covered and reimbursed, which then limits the payer’s exposure.”

Additional considerations, said Bach, are timeliness, cost management, communication and data management and compliance.

The number one consideration is always the patients’ needs and providing a safe and successful outcome

She shared some of the most valuable cost management tools in catastrophic cases: “These include case management, care coordination, case monitoring, medical necessity monitoring, coordinated prescriptions, discharge monitoring, continuity of care, detailed and clear communication with all parties, and of course provider arbitration and negotiation”. ITIJ also spoke with Elena Donina Glukhman, Business Development Manager, AP Companies Global Solutions, who said that case management is one of AP Companies’ strongest advantages. “We are able to manage a case and negotiate the length of stay, obtain discounts for high-cost treatment and, if possible and needed, move patients to higher-level, more cost-efficient facilities within the same area. All of the above may create the idea that managing catastrophic medical claims is straightforward, but there are many factors that influence the outcome and final cost of each case.”

Counteracting challenges at play
Indeed, managing catastrophic medical claims is a complex process with inherent challenges. Dr Ferial Ladak, Chief Medical Officer at Global Excel, said there are a wide range of financial, medical, patient and corporate client challenges at play. “On a very practical level, we often see the reluctance of the patient, their family, or the treating doctor, to let us repatriate the patient. Patients and perhaps their families often feel that the care they are receiving is superior to the care at home,” he told ITIJ. “The treating physician, who is often needed to issue a ‘Fit to Fly’ certification may have their own concerns, valid medical concerns for the patient, or perhaps certain non-medical financial considerations at heart. If the patient has family in the area, they may also have their own concerns.” Dr Ladak said that medical advances mean that critical patients can often be moved but there are other possible roadblocks. “We’re often faced with various other challenges from the patient or corporate client points of view.  Moving a patient solely for financial reasons does not go down well with anyone, except perhaps the underwriter or reinsurer.”

But, by maintaining a patient-first mentality and effective communication throughout, these challenges can usually be overcome, Dr Ladak shared: “We’ve almost always found that by keeping the patient’s wellbeing in the foreground at all points in time, and by working together with all the parties involved, we can create solutions that meet everyone’s best interests.” It is important to consider that numerous stakeholders are involved and everyone needs to be on the same page, which can prove challenging. Glukhman agreed with the importance of maintaining high-level collaboration and communication to minimise this: “The main challenge is that there are several parties that need to participate and be considered in such cases: the patient, the insurer, the family and the treating doctor. All parties should be in agreement on the steps that need to be taken, and often it takes time and effort to reach such an agreement. This can be challenging, considering that these decisions often need to be taken very quickly.”

Subhani said: “It is critical that challenging cases are handled with empathy, while also being open with patients and families about the full implications of their decisions. We always impress upon families that the patient’s wellbeing is the priority and that all measures for safety and health will be taken during repatriation. That said, it is also critical that they understand that they have purchased an insurance policy – be it travel, health, expat, etc. – which covers certain conditions under clearly defined parameters. This is always a delicate conversation to navigate, but we feel strongly that by communicating this clearly, compassionately and concisely, we are not only serving the payer but also the patient by informing them of the terms of the policy they have purchased, and ensuring that they understand that if they refuse a repatriation against advice, they may be putting their full coverage at risk.”

Bach said that there are challenges associated with cultural differences and language barriers: “The claims process and healthcare communication style can vary greatly between countries, when care crosses borders. There can also be language barriers that can make things difficult for a patient to understand during their care coordination.” In order to mitigate these challenges, New Frontier Group’s team is trained on the cultural aspects of countries around the globe and has multi-language capabilities.

By keeping the patient’s wellbeing in the foreground at all points in time, and by working together with all the parties involved, we can create solutions that meet everyone’s best interests

Subhani agreed: “Clear and honest communication is critical to effective case management and cost containment. Every country’s healthcare system works differently – for example, clinics are hard to come by in some countries and patients are more than likely to go directly to a hospital.  We supplement Penfield’s multilingual clinical team by maintaining ongoing relationships with translation services and local networks globally that we can activate at very short notice, ensuring that we are providing the right service for the right patient at the right time. By understanding the local culture we are better equipped to build relationships in the area, providing the highest level of service for all parties involved.”

Dr Glushak said there are struggles with procuring medical information quickly due to increasingly strict data regulations: “These days, obtaining prompt medical information has become increasingly difficult. Ever stricter data protection regulations have pushed providers into very defensive and protective positions regarding release of medical information, even when we have signed consent from the patient. This concern, plus the overload of work on providers, especially since Covid-19, makes furnishing useful and detailed medical information a lower priority for caretakers. Additionally, once readiness for repatriation and transportation is established, we are still facing a post-Covid-19 shortage of air ambulance options, as well as reduced capacity to allocate beds in patients’ home medical systems – the UK and Canada being especially hard hit. This can make it difficult to effect a repatriation plan when the window to initiate the next stage of care is narrow.”

Moving a patient solely for financial reasons does not go down well with anyone, except perhaps the underwriter or reinsurer

Repatriation requirements
When it comes to this repatriation step, Dr Ladak also pointed out the lasting impact of the pandemic: “Many national healthcare systems are strained as we emerge from the Covid-19 crises, and a lack of receiving beds is a challenge. Even if we find a receiving bed in a facility that can provide the quality of care needed, ensuring that the provider is located close to that patient’s home and/or family can often be an additional challenge.” Rummelhoff said the decision of when to repatriate a patient depends on a number of factors that need to be weighed up: “In some cases, transporting a patient can place them at a higher risk as the transport could exacerbate the damage, delay treatment, and introduce new complexities that could compromise the patient’s condition. In other situations, where a transport may not present those risks, it may be better to relocate the patient to a familiar network of providers in their home country where they have an expanded support system of family and loved ones close by.”

Glukhman told ITIJ that it is often preferable to repatriate a patient to bring them closer to their support system, but agreed that it is often not that simple: “When and where possible, AP Companies advises and assists in evacuating the member to their home country in order for the patient to be close to their family and receive necessary treatment within their state healthcare system. Having said that, it is prudent to bear in mind all details that could prevent all parties from such a decision: the patient may not be deemed fit to fly; the medical care in the home country/country of residence may not be sufficient for treatment of the medical condition; the patient may not be cleared for/able to travel with a commercial flight; and the limits of the policy may not allow long distance air ambulance costs.”

An untenable situation?
Reflecting on the point at which medical care overseas becomes untenable for the insurer, Bach said this depends on several factors: “The cost of the treatment, the policy limits and the specific terms and conditions of the insurance policy are factors to consider. For example, a case becomes untenable when the cost exceeds the coverage limitations, or there is no coverage at all.” Glukhman agreed: “Medical care overseas may become untenable when treatment exceeds policy limits, complications arise and long-term care is needed, or sufficient, higher-level care is not available in a particular locale,” she told ITIJ. Rummelhoff also said that an untenable situation arises for the insurer if the services required by the patient aren’t covered: “At times we may encounter situations where the patient has been treated and stabilised within a short period of time for an acute emergent condition. However, they may benefit and have better outcomes if they would receive services such as inpatient rehabilitation, outpatient cardiac rehab, or even outpatient physical and occupational therapy. Many times, these non-emergent services may not be a covered benefit.”

Given that the patient’s needs come first, Dr Glushak pointed out that putting them at risk would be avoided at all costs. “One cannot insist on repatriating or limiting essential care needed to ensure an acceptable medical outcome and which would put a patient at realistic risk in the process of transporting them to their home country, especially when current care is meeting their needs,” he told ITIJ. “The challenge comes when we experts know we can safely transfer a patient home, but the treating team feel they need to continue local care in a high-cost setting. This requires skilled communication at the assistance company end by physicians with unquestioned medical and aeromedical expertise and credentials to instil confidence in the treating providers.”

Ensuring high-quality medical care that is continuously monitored in order to deliver successful outcomes is the most important consideration when dealing with catastrophic medical claims. This is ensured through consistent, effective communication between stakeholders with patient safety kept at the forefront at all times.