How One Company Repatriated a Complex Claims Patient.
Managing a complex claim is one of the biggest challenges faced by medical assistance professionals. Each claim requires a highly adaptive approach, using specialized techniques, robust multidisciplinary strategies and flawless communication. Harmonizing these elements for success demands a very high degree of flexibility and creativity, in-depth medical knowledge and astute discernment, especially when working within different medical and cultural contexts around the world.
While the stakes are usually high – life & death, or permanent impairment – prognoses are often guarded, as the outcome depends almost entirely on ensuring the right care in a very complex situation. Additionally, teams must manage family members’ expectations, anxiety and the way they might interpret their loved one’s condition – well beyond the scope of simple medical assistance.
The following case, from Global Excel Management, illustrates just how demanding multidimensional complex medical claims can be, and how critical the very time-sensitive decision-making process is, where every move can have heavy human and financial repercussions.
Jeff1, a 62-year-old Canadian citizen from Montreal, was on vacation in Puerto Vallarta, Mexico. 3 days into his trip, he was feeling weak, barely able to stand, with episodes of bloody vomiting and stools. Worried about his condition, but unsure of his ability to tolerate the conditions of a waiting room, his wife called their health and travel insurance company for suggestions.
They used a new directional care program to evaluate Jeff’s condition and, from the description of his symptoms and his history of both heart and kidney disease, flagged his case as a high-risk medical emergency. He was to be sent by ambulance to a local emergency room for an initial diagnosis.
Jeff was admitted with hypotension (low blood pressure), breathing problems, and a generally deteriorating state of health. He was diagnosed with gastrointestinal bleeding, acute anemia (a precipitous drop in his red blood cell count) and hypovolemic shock (life-threatening body fluid loss): he was suffering from type 2 myotonic dystrophy (muscle deterioration), uremia (kidney disease) and coronary heart disease.
Jeff was intubated to assist his breathing, and underwent several endoscopies, which were unsuccessful in determining the source of his intestinal hemorrhaging. He needed multiple blood products that can be difficult to acquire in Mexico. Repatriation was decided upon as the most appropriate strategy, but the instability of his current state made the lengthy trip from Mexico to Canada too risky, even in a fully equipped air ambulance.
Global Excel’s medical team, with Jeff’s family, his insurance provider and the treating physician in Mexico, agreed upon an intermediary option: Jeff would be flown to an in-network hospital in Broward County, Florida, where he would benefit from higher quality health care.
In Florida, Jeff’s condition finally showed signs of improvement, after 7 days of closely monitored medical case management and daily attention from the multidisciplinary medical team in place.
As soon as his condition allowed, Jeff was repatriated by air ambulance to Canada and admitted to a Montreal hospital, where a private bed and a receiving physician had been secured.
Behind the scenes of this already complex case, a painstaking amount of work began the moment Jeff’s wife called in, to ensure optimal balance between costs and quality of care.
The early involvement of Global Excel’s directional care program allowed its cutting-edge Artificial Intelligence to instantly flag Jeff’s case as a medical emergency.
Communication with both the insurance company and Jeff’s other family members began immediately, informing them of his situation and any possible developments. Paperwork and authorizations were acquired to determine his medical history, especially concerning his cardiac surgery and kidney disease.
As soon as Jeff’s condition was diagnosed, his case was signaled as a potential large loss claim. Global Excel’s Reserve Department provided an estimate of the total cost of treatment if Jeff were retained at the hospital in Mexico, based on international medical guidelines for similar cases: over US$250 000.
Repatriation was identified as the best option for Jeff’s situation, but the instability of his current state made the lengthy trip from Mexico to Canada too risky, even in a fully equipped air ambulance. Consequently, an intermediary treatment period, which would further stabilize Jeff’s condition, was scheduled in Florida.
The transfer to a US hospital was not governed solely by cost, but also by the need for a better quality of care. The Mexican hospital had planned to do a laparotomy to locate the source of the bleeding, but this sort of intervention was not coherent with best practices. The Global Excel medical team felt Jeff needed access to more cutting edge investigational tools.
But there was also a second issue at hand: blood products are scarce in Mexico, and the blood used to treat Jeff, while compatible with his blood-type, was not completely typed for his profile, putting him at risk for a reaction to the transfusions, further complicating his outcome.
Air ambulance transportation was quickly arranged to fly Jeff to the nearest in-network hospital, greatly simplifying both the admissions process and the exchange of relevant information. This made it easier for Global Excel’s medical team to get involved in the treatment strategy early on, ensuring policy wording, medical guidelines and best practices were followed.
Once transportation arrangements were in place, Global Excel’s medical team conducted regular, thorough follow-ups on Jeff’s treatment. They engaged in exhaustive discussions, both internally and with the Treating Medical Office (TMO) to determine the best course of action in managing the case’s complexities. Detailed planning occurred to ensure Jeff’s best interests were respected, including the quality and availability of all necessary care: Global Excel’s experienced medical team was familiar, for example, with the scarcity of certain blood products in Mexico, and kept in mind the costs incurred by Jeff’s insurance company.
Stabilizing Jeff, then flying him to the nearest in-network hospital in the U.S. for a higher quality of care was decided upon as the best option globally, meeting all constraints and demands. Once his condition improved, he could then be flown back to Canada for his recovery. Overall, this strategy, as simulated by Global Excel’s financial teams, was estimated to save about 40%, while ensuring better care than if Jeff continued treatment in Mexico.
All options were discussed with both Jeff’s insurer and his family. Once plans were agreed upon by all stakeholders, preparations began so Jeff could be moved as soon as his state allowed.
The moment Jeff’s TMO in Mexico gave the green light, Jeff was flown to Broward, immediately admitted to the CCU and closely monitored by both a local multidisciplinary team and Global Excel’s medical team, while the appropriate treatments continued.
Improvements in Jeff’s condition were quick to notice and, a week after admission to Broward, he was deemed fit to fly to his home country, where he would continue further treatment in a Montréal hospital, close to his family.
Complex claim management is one of the most challenging aspects of the medical assistance industry. Each case is different, and each solution must be tailored to a case’s complexities: the medical prognosis, the quality of care needed and available, the host country’s healthcare system and the financial impacts of each option.
The inherent complexity of the field requires a complete mastery of medical assistance techniques, a highly responsive, agile team who can quickly conceive robust strategies and execute creative solutions while anticipating all possible scenarios.
This requires a multidisciplinary team of experts who’ve honed their skills in accurately assessing the implications of each decision, who possess a thorough knowledge of healthcare systems around the world, supported by a robust network of medical providers. These professionals are sustained by Global Excel’s unique Artificial Intelligence solution, which instantly activates an experienced medical team and exploits specialized internal processes and communication tools to provide real-time crucial information to all involved. The overall combination is a highly efficient method in resolving complex medical cases worldwide.
In addition, providers must facilitate admissions, quickly and clearly exchanging all relevant information as early as possible – key to both a successful decision-making process and flawless case coordination.
Finally, all of this must be imprinted with understanding and compassion for both the patient and his family members, often overwhelmed by the emotional aspects of their own highly stressful situation.
1 Patient’s name has been changed to protect their identity and their privacy