Be good stewards of patients' health benefits
Be good stewards of patients' health benefits
Look beyond the current episode of care
When B.K. Kizziar, RN, CCM, CLP, speaks to groups of case managers, she asks if they know how many home care visits their own health care will provide. Few raise their hands.
"If we as health care professionals don't know our own benefits, how can we expect the patients and families to know what benefits they have for hospitalization and post-acute care?" asks Kizziar, owner of B.K. & Associates, a Southlake, TX, case management consulting firm.
"Our role is to find out the patient's benefits, whether it's commercial insurance, Medicare, Medicaid, or self-pay. We need to know what we have to work with. Otherwise, we may be recommending things that the patient simply cannot have," she adds.
In addition to affecting the reimbursement the hospital receives, the type of insurance a patient has will have an effect on his or her out-of-pocket expenses for a hospital stay, says Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital.
"There is a responsibility to be a good steward of patients' resources among the entire treatment team but the coordination falls back on the case manager," Cunningham says.
Case managers need to know what coverage a patient has in order to tailor the treatment and discharge plan to minimize the out-of-pocket expenses, she says.
For instance, you may be coordinating the care of four patients with pneumonia, each of whom has a different kind of insurance coverage with benefits that have an impact on the optimum discharge plan. One may be on Medicare and can't go home with IV antibiotics because Medicare won't pay for it. The second one may have a PPO that will allow the patient to stay in the hospital as long as needed, based on their criteria. The third could have an HMO that wants to get the patient discharged as soon as possible and will pay for IV antibiotics at home. The fourth may have no insurance at all.
"Every one of these patients has a different financial responsibility at the end of the stay. Each insurer will pay a different amount and each patient will have different out-of-pocket expenses," Cunningham points out.
In order to plan a successful discharge, case managers also need to be aware of the patient's benefits outside the hospital benefit, Kizziar points out. For instance, a patient might benefit best from a skilled level of care but if he or she has no benefits, the case manager needs to find an alternative.
Case managers need to know what community resources are available to take up the slack when a patient can't pay for care after discharge.
"We often are interested only in the benefit for the care we're immediately managing but there are often far-reaching implications to our discharge plans," Cunningham says.
Take a step further
Take it a step further and look beyond what your patients need during the current episode of care and be a good steward of their benefits to assure that they will have coverage later on in the year, Kizziar says.
Take the patient's full benefit for post-acute care into account before setting up visits for home care or other post-acute services, she adds.
For example, patients with chronic diseases, such as chronic obstructive pulmonary disease often need home health visits after discharge.
If the patient only has 20 home health visits a year and you set up five a week for several weeks, the patient may end up having to pay out of pocket for a lot of home health expenses later in the year.
Look at whether the patient really needs daily visits for four weeks or if he or she could have daily visits for a few days, then biweekly visits.
"If case managers look past the current situation to what the whole year may bring, we can be a better advocate for patients and help them maximize their benefits," she says.
Case managers also should pay attention to the maximum coverage a patient has and take steps to avoid delays in treatment that could result in excessive out-of-pocket expenses, Cunningham adds.
"There are situations where patients may have a maximum of $20,000 coverage for the year. If a patient in this situation ends up staying in the hospital for extra days because his or her physician doesn't schedule the surgery in a timely manner, or there are delays in getting the results of tests, the patient could end up being responsible for a huge bill," she says.
When B.K. Kizziar, RN, CCM, CLP, speaks to groups of case managers, she asks if they know how many home care visits their own health care will provide. Few raise their hands.Subscribe Now for Access
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