Ensuring Union Members Benefit from Quality Care and Sound Healthcare Decisions
As a union representing workers in many industries, UFCW Local 555 wants to ensure its members have positive experiences when using their health coverage. To advocate for its members and solve the sometimes-complicated challenges that can arise when dealing with prior authorization processes and potential denials, Local 555 works with Innovative Care Management.
Advocating for Workers
Local 555 is a labor union representing workers in Oregon, Idaho, and Southwest Washington. There are more than 30,000 members, and they work in a variety of industries, including retail, manufacturing and healthcare.
In addition to helping members understand and exercise their rights, Local 555 provides access to healthcare and retirement benefits.
Local 555 provides health coverage through a self-funded plan, using the Regence Blue Cross Blue Shield network. Dan Clay, the President of Local 555 and a trustee for its employee health trust, has been happy with the network. “Inside Portland, they’re helpful, but outside Portland, in the rural areas, they’re essential,” Dan explains. “We haven’t found any other networks that could get the kind of discounts in these rural hospitals where hospitals have an ability to charge a lot more. Savings are meaningful for the trust.”
Negotiating a Joint Administrative Agreement
With Local 555’s support, Regence BCBS and Local 555’s third-party administrator, Zenith American Solutions, negotiated a joint administrative agreement, allowing them to collaborate on plan administration, while giving Local 555 greater control over coverage.
In addition to allowing Zenith to administer the plan using the BCBS network, the JAA also allows a third party to provide utilization management. For this, the Plan relies on Innovative Care Management (ICM).
Human-Centered Care Navigation
ICM’s human-centered medical management services complement Local 555’s commitment to member advocacy. At a time when some organizations are accused of putting profits over people, ICM strives to balance compassion with clinical evidence.
When requested, ICM provides preauthorization/ medical necessity review, and in cases involving an urgent situation or a care denial, ICM assists the plan or the member in getting a reconsideration or an appeal, which can result in a different outcome.
Although health plan members can file appeals on their own, the process can be confusing and time consuming, and members don’t always have the luxury of waiting for reviews when they are in urgent need of care. ICM helps by handling the research and presenting the findings. If the clinical evidence supports approval of the claim, the denial may be overturned.
In some cases, ICM’s expertise can yield better, faster results.
Dan recalls a situation involving a long term employee, where ICM made a meaningful difference. “Our member had a tumor in her brain, and the treatment recommended by her specialist was denied,” Dan says. “She could appeal, but the process would take 60 to 90 days – essentially a death sentence for someone with that diagnosis.”
The member needed treatment for her brain tumor immediately, so Dan took action.
“I made a couple of phone calls to ICM, and they responded in less than 48 hours,” says Dan. ICM’s research supported the doctor’s assessment. With ICM’s clinically-backed recommendation, the treatment was quickly approved. She had the surgery within a week.
“Innovative Care Management didn’t treat it like just another thing,” Dan says. “They cared about that person. That person matters.”
“If I had a family member with a health problem, and they were going to be interacting with any number of providers we deal with for healthcare, I would feel most comfortable with letting Innovative Care Management provide guidance.”
Dan Clay
President of Local 555
Sound Reasoning
Local 555, through its joint labor-management Health Trust, has partnered with ICM for more than 10 years now. The relationship has endured over the years because ICM helps Local 555 achieve its goals of member advocacy.
“Healthcare is looked at as sniffles and sprained ankles,” says Dan. “But good healthcare is fundamentally about life. It’s about quality of life, but even beyond that, it’s about a generational financial stability. For people who work for a living, it matters a lot.”
While ICM is approvals based, there are times when services are denied for clinically sound reasons. In these cases, the rationale is clearly presented and all opportunities for reconsideration or appeals are provided.
As Dan explains, “The role of ICM is to look at the situation and say, ‘This is what ought to be done here, based on what the rules are.’ Sometimes they say yes, sometimes it’s no. But in all cases, I understand why.”
The Same Care You'd Want for Your Loved Ones
Many organizations claim to treat their workers or members as family. This raises the question – would you choose the same healthcare services for your actual family?
Dan would. “If I had a family member with a health problem, and they were going to be interacting with any number of providers we deal with for healthcare, I would feel most comfortable with letting Innovative Care Management provide guidance.”