Symetra Financial - Together We’re Better! Managing the High Costs of Kidney Disease


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Together We’re Better! Managing the High Costs
of Kidney Disease

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By Delois Howell, RN, BSN, CCM, LHRM, and Lily Willson, RN, BSN, CCM, ARA, ACS Medical Risk Consultants for Symetra Life Insurance Co.

As we have explored in previous articles¹, chronic kidney disease (CKD) is a costly health care concern for many Americans. Like many medical conditions, the key to the prevention of CKD is early detection. At each stage of the disease, there are opportunities and preventative actions that can be taken to improve patients’ outcomes. Working together, we can identify the best approaches to managing this high-cost and catastrophic disease.

The two main causes of chronic kidney disease are diabetes and high blood pressure. Early patient education and detection is essential to managing the disease. Employer Wellness programs and health care screenings and assessments can be effective in early detection. Case management and disease management play pivotal roles in preventing and delaying the disease’s progression to kidney failure.

Working together
Symetra has partnered with many providers and healthcare organizations to assist in the management of chronic kidney disease. Our team of Medical Risk Consultants (MRCs) is a resource for cost containment efforts and helps support the transition from patient education to dialysis and transplantation.

The five stages of chronic kidney disease serve as windows of opportunities to manage the disease progression, reduce cost of treatment, and lessen the impact of large claims. With early identification and joint management of the disease and dialysis claims, third-party administrators (TPAs) and Symetra can work together to improve the outcome for the patient, preserve the lifetime benefit of the member and realize significant savings for the policyholder.

Here are some examples of how TPAs and Symetra MRCs work together throughout the five stages of CKD. (Click here for a printable version of this chart.)

Stage	CODE	TPA Action	Symetra MRC Action
1	585.1 Slight damage	Patient identification Patient Education Disease Management	Monitor notice Vendor/provider resource
2	585.2 Mild decrease in function	Disease Management Patient Education Physician Management	Disease Management referral source Monitor notices Monitor claims information
3	585.3 Moderate decrease in function	Disease Management Medicare Education - ESRD Case Management Pre-treatment dialysis management options	Coordinate access to specialty pharmacy vendors Provide access to CKD providers Discuss ESRD claims management options Offer resource for ESRD plan language
4	585.4 Severe decrease in function	Send itemized bill to Symetra for claim review Case Management Case Management reports to Symetra Medicare Education Educate & encourage participant enrollment in Medicare’s ESRD Benefits Patient education Types of dialysis Treatment options	Screen itemized claims for re-pricing/negotiation. Provide access to Transplant Networks Discuss ESRD claims management options Review clinical resources and treatment options Determine Medicare B for ESRD effective date for secondary and primary coverage
5	585.5 Severe 585.6 End Stage requires dialysis or transplant	Same as Stage 4 Submission of ongoing large claims for re-pricing/ negotiation.	Same as Stage 4 Provide Management and savings reporting of high dollar ESRD claims. Provide access to Transplant Networks and monitor outcomes

An invested partner
At Symetra, we view our role in kidney disease management as that of an invested partner, and we take an “owner’s interest” in managing the disease. Our goal is to work together to deliver the best possible outcome for the management of catastrophic illnesses.

To access our network of vendors and our MRC services, please contact your designated Symetra Stop Loss claims office.

Lily Willson RN, BSN, CCM, ARA, ACS is a medical risk consultant (MRC) for Symetra Life Insurance Company. She has more than 23 years combined experience in the medical field and health insurance industry. She holds a LOMA Associate in Reinsurance Administration certificate.

Delois Howell, RN, BSN, CCM, LHRM, is a medical risk consultant (MRC) for Symetra Life Insurance Company. She has more than 25 years combined experience in the medical field and health insurance industry.

¹ For more information, please read and

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