Resources

Situation
A member with a rare condition required ongoing specialized care, but MRI coverage limits put his treatment continuity at risk. His health plan included a maximum payable (CAP) limit for high-tech imaging services, which could have led to significant out-of-pocket costs and disrupted his ability to continue treatment at his preferred provider.

Intervention
Through the High-Tech Imaging Outreach Program, the Communitas Advocacy team connected with the member and coordinated with WebTPA Account Management to renew the exception each year, maintaining uninterrupted access to his treatment.

Outcome
The member maintained uninterrupted access to needed treatment with no additional out-of-pocket burden. This support helped avoid unnecessary or inconclusive procedures elsewhere and improved overall satisfaction with his healthcare experience.

Situation
A member had an upcoming MRI scheduled at a hospital and was facing an estimated cost of $800, which she could not afford. She was unaware that choosing a different facility could significantly reduce her out-of-pocket expense.

Intervention
The Advocacy team proactively reached out to explain her high-tech imaging benefits and educated her on lower-cost alternatives. They guided her in transferring the order to a freestanding imaging center, where costs are typically much lower.

Outcome
The member successfully switched providers and reduced her financial responsibility from $800 to just $81.26. She was able to receive the needed imaging without financial strain, resulting in significant savings and an improved healthcare experience.

Situation
A member with a chronic condition had three upcoming MRI scans scheduled at a hospital, with estimated costs of $3,248 to $6,300 per scan. Although concerned about the expense, she was initially hesitant to switch providers due to her long-standing relationship with the hospital.

Intervention
The Advocacy team educated the member on cost-saving options and provided a list of in-network independent imaging centers with lower estimated rates. They guided her on working with her physician to transfer the orders to a more cost-effective facility.

Outcome
All three MRI scans were successfully completed at an independent imaging center at a contracted rate of $475 per scan. Because the member had already met her deductible and out-of-pocket maximum, the scans were fully covered. 

Situation
A member needed help finding a speech-language pathologist (SLP) for her twin children, who had motor and speech delays. Their previous virtual therapy showed little progress, and scheduling challenges after school made consistent care difficult.

Intervention
After in-network options did not meet the children’s needs, the Advocacy team worked from school recommendations to coordinate a Single Case Agreement with a private therapist. This allowed the therapist to provide services directly at the children’s school, improving access and consistency.

Outcome
With in-person therapy in a familiar setting, the children began thriving and showing meaningful progress. Their mother expressed gratitude, sharing that this outcome “would not have happened” without the support she received.

Situation
Repeated claim denials left a member facing a $17,322.50 cancer-related bill.

Intervention
The Advocacy team provided ongoing support by reviewing inquiries and escalating issues for resolution. They worked to have the high-cost claim reprocessed and addressed multiple previously denied claims.

Outcome
The $17,322.50 claim was successfully reprocessed and paid at 100%. All prior denied claims were also resolved, giving the member peace of mind that his major financial burdens were eliminated.

Situation
During a routine new member outreach call, the Advocacy team spoke with a member who shared that she urgently needed to go to the hospital. In the conversation, it became clear she needed immediate guidance on where to seek care and how to use her new plan benefits.

Intervention
The Advocacy team explained her urgent care benefits, identified a nearby in-network facility she was familiar with, and guided her on how to access care quickly. They also provided her ID card details in real time when she couldn’t open the attachment and advised the facility on how to verify coverage.

Outcome
The member was able to confidently visit Urgent Care and receive timely treatment. She accessed care without delays or confusion and gained a better understanding of how to use her benefits moving forward.

Situation
A member called in to speak with an onsite nurse after seeing an oncologist, as there was a high suspicion of prostate cancer, but a biopsy was required to confirm.  He needed a new in-network urologist, but kept encountering referral delays, causing him significant stress and anxiety.

Intervention
The onsite nurse successfully coordinated the referral between the oncologist and the new urologist. She made multiple follow-up calls to confirm the receipt of the referral and expedite scheduling, and she also advocated for an earlier appointment due to clinical urgency and member distress.

Outcome
A new appointment was made two months earlier than expected, and the member’s dilemma had been resolved to their satisfaction within 48 hours. The onsite nurse’s action not only helped avoid out-of-network costs but also prevented potential complications due to a delay in care.