CareCounsel Offers Health Care Quality Ombudsman Program

San Rafael, CA, October 9, 1997 — CareCounsel, LLC is a new company that responds to the growing demand for independent programs that provide assistance to health consumers as they navigate the changing managed care environment. This trend has accelerated with the recent announcement that three HMO industry leaders have joined with two leading consumer organizations in a groundbreaking agreement supporting new policies to protect Americans enrolled in managed care plans.

The five organizations that collaborated on the agreement are Kaiser Permanente, Group Health Cooperative of Puget Sound, HIP Health Insurance Plans, the American Association of Retired People and Families USA.

A significant proposal is the provision that health plans should offer access to an independent "ombudsman" program to help people understand managed care coverage and benefit issues, educate members about their rights, investigate complaints, help members file grievances and appeals, and provide consumer education and information. The initiative also calls for establishing an external, independent review process to examine the cases of seriously ill patients who are denied coverage for experimental treatments.

CareCounsel was founded to meet the needs of employers and other purchasers of group health benefits who desire to give their beneficiaries access to an independent "ombudsman" program that responds proactively to employees' anxiety about access, service and quality issues in managed care. CareCounsel offers "CareCounseling" for healthcare consumers, health information, senior care referrals and access to Cancer Quality Care Review services through Memorial Sloan-Kettering Cancer Center.

Employees call a toll-free number for help regarding managed care or health benefit issues. They also can request information regarding just about any health or disease topic. Licensed RN's and masters' level health professionals answer questions about how to select a health plan, how managed care works, and how to resolve service problems. Most callers receive counseling and assistance, often in the form of coaching, to take a more active assertive role in their medical interactions. Others receive printed educational material, covering topics like "Selecting a Primary Care Physician," and "How to Obtain Your Medical Record." Other calls result in referrals to the appropriate plan's customer service function, to a state regulatory agency, medical board or disease-related support organization. Finally, CareCounselors provide ongoing assistance, researching more complex issues with the consumer's health plan, provider or employee benefit staff. The employer receives comprehensive reports tracking program use by issue type, plan and location.

People facing the potentially life-threatening illness of cancer also have access to the Cancer Quality Care Review Program. After board-certified specialists at Memorial Sloan-Kettering review their pathology slides, radiography reports and medical records, the CareCounsel member receives a written report that gives a detailed assessment of the accuracy, completeness and overall quality of their diagnosis and treatment recommendations. When medically appropriate, the report also includes information about additional treatment options. CareCounselors are available to help members present the findings to their physician, access cancer support resources, offer childcare and elder care referrals and, if necessary, act as an advocate with their health plan.

Back to In The News