This 51-year-old male was identified for case management during his admission to the hospital for weakness of the left upper extremity and - slurred speech. Claimant was being treated in local hospitals, by multiple physicians without the benefit of currently recommended drug protocol for AIDS, including protease inhibitors. Approval was obtained from the plan administrator and the hospitals agreed to submit claims for prompt payment through the case manager, who would expedite process. The claimant stopped the use of heroin at the time of the HIV diagnosis and up until 1 year prior to the hospital admission had received no consistent medical care. The claimant did agree and the case manager made the arrangements and attended the appointment with him and his wife. …show more content…
His condition began to improve; however, in one of her follow-up calls to the claimant, the case manager, learned that he had abruptly discontinued the protease inhibitor because of pain and left side abdominal bloating: Intervention: Remembering from her review of claimant's medical records a finding of a left adrenal tumor 1 year ago (felt to be benign but with advisory for reevaluation in order to monitor size, etc. These included at least two hospital admissions (secondary to noncompliance and the resulting complications or deterioration of his condition) and duplication of testing and doctor visits as the claimant continued his pursuit of treatment from multiple physicians without appropriate expertise. Case manager called the physician group, explained concerns of claimant and asked for names of university-affiliated infectious disease specialists nearer to the claimant's home or place of work. Case manager contacted plan administrator and obtained approval for physician selected by