Provider Spotlight: Going Above and Beyond
Posted on September 12, 2016
When our providers go above and beyond to ensure quality care for patients, they also often help pass along cost savings to our members and employer groups. Recently one provider at a local Louis & Clark medical equipment & supply store did just that.
Health New England had been working with a Be Healthy member with a spinal cord injury who is paraplegic. Upon being discharged from his rehab facility, the member was given a prescription for a type of expensive catheter that is not normally ordered. MassHealth allows one catheter per day (or 30 per month) and the prescription was written for six per day (or 180 per month).
That’s when Wally, a Louis & Clark employee, stepped in. Recognizing that the member had no clinical documentation from the nurse practitioner who ordered this catheter type, Wally questioned the medical necessity behind the order. He made multiple attempts to contact the provider for a clinical note. Eventually he took it upon himself to research different types of cost effective catheters and found six different alternatives.
In the meantime, a request was made to the member’s PCP for a nurse to go into the home to observe and educate the member on use of the catheter. After learning that the nurse was not scheduled to enter the member’ home for a week after the request was made, Wally personally drove to the member’s home (with his permission) and dropped off the catheters at the end of the business day.
By helping the member reduce his catheter order from 180 to 30 per month, Wally helped ensure proper care and effective use while saving approximately $8,000 in medical expense.
Health New England thanks Wally and Louis & Clark for helping our member!
