The life-changing impact of nurse advocacy

Grace Campagna

If you’re a parent you can certainly identify with the deep concern that comes when your child comes down with an illness. Now imagine encountering a roadblock to medical care for a child who has significant medical issues. Concern turns into fear and frustration.

I’d like to share how we assisted two different families to access treatment and medication for their children through our optional NurseVIP service, which gives insurance plan participants access to registered nurses who possess special consultative skills and healthcare industry expertise. NurseVIP operates as an extension of our employee advocacy and support center, BenefitsVIP. NurseVIP is staffed with registered nurses who provide guidance and support when an employee faces a surgery, hears an unexpected diagnosis, or needs help getting care for a loved one.

NurseVIP advocates do not provide medical treatment. Instead, they work on behalf of the employer’s group insurance plan participants to coordinate care with doctors, hospitals, visiting nurses, testing facilities, nursing homes, equipment suppliers, community services providers, etc. They also help patients and family members understand treatment options so they can make informed decisions.

Here are the two cases I referenced above that illustrate the impact of nurse advocacy:

Our first case involved a pre-adolescent girl who suffered from an unusual and complex medical condition that required frequent hospitalizations and regular intravenous of calcium. The child’s symptoms improved during her involvement in a clinical trial for an osteoporosis drug that had been only approved for adult use. The drug used in the clinical trial stabilized her condition and kept her out of the hospital. That’s the good news.

But after the trial ended, the girl’s parents wanted her to continue on the medication. They encountered a road block when the insurance carrier denied covering the drug because it’s only approved for adults. You can imagine the parents’ panic; they were running low on the medicine left over from the clinical trial and were trying to stretch it to make it last. Then their daughter had to be hospitalized again. The parents reached out to a Corporate Synergies NurseVIP advocate who went to work to resolve the issue.

Based on an evaluation of the child’s medical records, the NurseVIP advocate knew the health insurance carrier would deny payment and the only option for a rapid and successful outcome was to appeal the case directly to the drug’s manufacturer. She spoke to the drug company’s team of doctors and nurses and encouraged them to evaluate the case. She also requested that the company supply the child with the medication—and at no cost.

The drug company wouldn’t have considered the child for a patient assistance program because children aren’t approved for the osteoporosis medication. But the manufacturer agreed with our NurseVIP advocate that the drug was necessary for the girl’s well-being. They also agreed to provide the medication free of charge.

If the NurseVIP advocate hadn’t intervened in this case, the child would not have access to the drug and faced repeated and costly hospitalizations. The involvement of the nurse advocate also prevented the child’s father’s employer (who’s our client) from paying higher healthcare costs for unneeded hospitalizations. It’s noteworthy that the entire process to obtain the drug for the girl took the nurse advocate less than 30 days.

In the second case, an employee working for our client received some bad news: his primary care physician said his pre-school age son required an evaluation by a developmental pediatrician. The employee immediately contacted the specialist on his own and learned his schedule was booked for more than six months. His child would have to wait for an evaluation. Unfortunately, this physician was the only in-network developmental pediatrician in his area and was highly recommended. Seeking an evaluation by an out-of-network specialist was not an option for the employee due to the higher out-of-pocket expense.

The worried employee contacted BenefitsVIP, who referred the case to our NurseVIP advocacy service. A nurse advocate investigated and determined that the boy shouldn’t wait several months for an evaluation due to the severity of his condition. Before reaching out to the developmental specialist, she confirmed that the employee’s insurance coverage would cover this doctor’s evaluation and treatment.

The NurseVIP advocate immediately contacted the office manager at the provider’s office and discussed the details of the boy’s case. The office manager concurred that due to the child’s young age and the seriousness of his condition, the medical evaluation should not be delayed for six months. Our nurse advocate secured an evaluation appointment with the developmental physician to take place within three weeks of making the first phone call.

The child was evaluated and received the appropriate diagnosis, and the specialist recommended a course of therapy. Our advocate interceded with the specialist’s office again to schedule the therapy, and the child immediately began receiving treatment. In all, the NurseVIP advocate’s contacts with the specialist’s office entailed only about 90 minutes, but her actions will have a significant impact on the boy’s life and that of his family.

Employee benefits are complicated by nature and there are a lot of behind-the-scene factors that come into play when plan participants seek medical treatment or buy a prescription. The NurseVIP advocate’s goal is to replace stress and frustration with peace of mind. And in the process, the advocate can change a life.

Contact us for the full case studies: NurseVIP Vital Rx Access and NurseVIP Rapid Appointment Scheduling.