What a care manager is — and isn’t

Care managers do a lot. Their job is to reduce treatment costs and hospitalization rates, eliminate unnecessary and redundant testing, prevent adverse medication interactions and boost patients’ emotional well-being.

With six in 10 Americans coping with complex and chronic health conditions, care management has become an important tool for insurance companies and hospitals as they work to coordinate care and contain costs.

And they can have a positive impact. I recently read of a woman being treated for breast cancer who had nothing but praise for the care manager assigned to her by her employer’s insurance carrier.

What don’t care managers do? They don’t work for the patient. At least not exclusively.

This is concerning to me because I’ve encountered care managers who call themselves patient advocates. Hospitals and nursing homes also have “patient advocates” who are, in fact, assigned to the risk management department. Their main job is to manage patient complaints and keep the facility from being sued.

While these folks do advocate for patients, they are not patient advocates. This can be confusing for someone experiencing a health crisis, so it’s important to understand the differences.

Here are some ways you can tell them apart.

1. Who’s paying the tab?

If the hospital or insurance company — or even the county or state’s social services department — is paying, then the care manager is not the patient’s advocate. They are beholden to their employer. If, on the other hand, the services are paid for by the family or the patient, then they are a patient advocate.

This is an important distinction. A private patient advocate can be thought of as providing concierge services to the client, and the well-being of that client is the advocate’s only concern.

2. Who’s representing the patient’s best interest?

To advocate essentially means to represent the needs of another. Patients and families hire private patient advocates to stand in the gap and make certain their personal interests are protected, dealing with insurance companies, vetting the best providers for rare disorders, and making sure the right questions are being asked.

3. Who’s reviewing medical bills and insurance payments?

A care manager working for a hospital or insurance company is not very likely to be willing to review medical bills and insurance payments looking for errors and underpayments. It’s one of the services patient advocates can provide. With our knowledge of health care, we can review detailed hospital bills, looking for duplicate charges or things that just don’t make sense.

This is not to say that patient advocates and care managers are adversaries. Far from it. We can work as partners for the benefit of our client. One example is communications. A care manager can provide information to a patient advocate in just a few minutes that might take 20 minutes to make sure the patient and family members understand.

For their part, patient advocates can provide the client with more in-depth instructions, monitor compliance and watch for medication side effects. And when we are monitoring patients in their homes (something a care manager is unlikely to do), we can catch early signs of trouble and get medical help before it escalates into a full-blown crisis. We act like a “nurse in the family.”

One common goal of both patient advocates and care managers is that we want our patients to participate in their own health care. Sometimes this isn’t possible because of cognitive issues, but we do everything we can to explain to the patient what’s going on. The care manager can help make health care easier and less overwhelming for hospital patients and insurance members, helping them to understand the types of services available. They can also help with setting up referrals and prior authorizations that may be required by the insurance company.

Although patient advocates and care managers share similar responsibilities, they are different enough to warrant their own field of expertise and practice. There are even certifications for each.

A number of public and private institutions now offer certificate programs in patient advocacy, and I encourage clients to look for board-certified patient advocates. A care manager may have credentials from the National Academy of Certified Care Managers or have the Certified Geriatric Care Manager designation.

Care managers play an important role in health care. While it’s good for care managers and patient advocates to work together, one shouldn’t be confused with the other.

• Teri (Dreher) Frykenberg is a board-certified patient advocate. A critical care registered nurse for 30+ years, she is founder of NShore Patient Advocates (www.NorthShoreRN.com). Her book, “How to Be a Healthcare Advocate for Yourself & Your Loved Ones,” is available on Amazon. She is offering a free phone consultation to Daily Herald readers; email her at teri@northshorern.com.