Care Navigation

Care navigation is a service that helps a plan member find the right care: which doctor, which facility, what it will cost, whether prior authorization is needed, and what to do when a bill looks wrong. It can be a phone line staffed by nurses, a concierge team, an app, or some combination. The navigator works for the member or the plan, not for the hospital.

The need for it comes from how little the system explains itself. A member told they need a knee replacement typically gets a surgeon's name and a date, not a comparison of facilities, complication rates, or prices that can differ by $20,000 across town. Navigation vendors charge $3 to $12 per employee per month and generally report savings of a few times that, mostly from redirecting imaging, labs, and outpatient surgery to lower-cost settings and from catching billing errors. The results depend heavily on whether members actually call. Programs that reach out when they can see a procedure coming, through a prior authorization request for example, get used far more than programs that wait for the phone to ring.

The takeaway: if you have a navigation benefit, call it before the appointment, not after the bill. One conversation before a scheduled surgery is worth more than ten after.