Pro-Active Cost Avoidance

55 year old male spouse with diabetes. Initial risk stratification of the Plan’s diabetics for disease management by the Vigilant software/nurse navigator NP revealed that this individual had a renal transplant two years previously, unrecognized by the Plan or the TPA. Claims records revealed that he had had consistent follow up at the UMMC renal transplant clinic for 6 months, but that ALL claims on the Plan for this individual, and all medical care, had ceased 18 months prior. The situation was deemed dire enough that the Clinic approached the HR Safety Officer and obtained permission to contact the patient. The patient, once he had received his transplant and was urinating again, had decided he did not need further medical care so had ceased all follow up, including transplant follow up, transplant meds, and diabetes management, the cause of the original kidney loss. This discovery by the Clinic led to re-establishment of regular medical care, preservation of his transplant, and the resumption of management of his diabetes, avoiding a very highly probable, and very tragic, catastrophic cost to the Plan.

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