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Old 02-17-2013, 10:33 AM   #67305
LadyV69
 
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Join Date: Oct 2009
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I would be glad that I have a long weekend now but I’m on call for the first time in awhile. And wouldn’t you know I got a call from an independent review entity at 9am yesterday? Someone from a member’s family wants to appeal something. Our company is supposed to operate from 8-8 every day but we're only physically in the office Mon-Fri from 9-5. The rest of the time we're on call. The care management department usually emails the department a list of people and materials for any possible appeals that we may get over the weekend and they didn’t send us anything whatsoever for this particular person. So I had no idea why this member would appeal anything as she wasn’t on any list. After speaking with my supervisor on the phone, it turns out we had gotten an appeal from her family last week. She was inpatient at a hospital and they wanted to discharge and transfer her into a skilled nursing facility. They never did so as the member’s condition worsened. Now the facility wants to discharge this member again and the family isn’t having it. The thing is, the facility never told the plan that they intend to discharge her. I had to call the Supervisor of Care Management for more information. That person stated that the last thing that the hospital told the plan was that the member had a fever on Friday. The plan usually doesn’t want the member going anywhere with a fever but we didn't know what the facility was doing because now they want the member discharged. Does the member not have a fever now? We didn't know, because no one was able to get a hold of anyone at the hospital yesterday for more info. This morning, the Care Management Supervisor finally got a hold of someone at the hospital who said the member is stable and is ready to be discharged but the family wants her to stay there (why I have no idea). We're now waiting for the hospital to send some documentation to the CM supervisor so she could issue a notice to this review entity that will actually be handling the appeal. But as of now, the hospital hasn't sent anything. I should not be this stressed on a Sunday.
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