Aetna Member Story

An Uplifting Member Success Story That Reinforces The Vital Role Health Plan Utilization Management Teams Play In Successful Member Care Coordination

An uplifting member success story that reinforces the vital role health plan utilization management teams play in successful member care coordination:

MEMBER’S BACKGROUND INCLUDES: Recent substance abuse, delusional thinking, confusion, bizarre behaviors, urinary incontinence, repetitive language, and issues with motor skills.

This is a success story about a member who was admitted to the mental health inpatient unit with the following presentations: recent substance abuse, delusional thinking, confusion and bizarre behaviors. These are often typical presentations for a behavioral health admission. During live reviews with the facility, a health plan Utilization Manager questioned some of the presenting factors that didn’t seem to be part of the member’s behavioral health presentation, including urinary incontinence, repetitive language and other issues with motor skills. Due to the Utilization Manager’s persistent inquiry, the facility ordered a CT scan and a left hemisphere brain mass was located. The member is now receiving medical treatment at a local hospital. Through careful review of documentation, thorough follow-up and close collaboration with the facility, the health plan was able to advocate for the member and intervene on the member’s behalf, helping her receive an early medical intervention and the proper treatment for her medical condition.

*Names changed to protect privacy