Cracking the managed care payment nut
Cracking the managed care payment nut
(Editor’s note: This is part one of a two-part series on speeding payment for private duty services from managed care organizations. In the next installment, Private Duty Homecare will give tips for meeting payer’s billing requirements and the use of available technology to help speed payments.)
Managed care accounts are often the thorniest to collect, using tremendous staff resources and tying up huge amounts of receivables. Yet both payers and providers say managed care dollars can flow more quickly by avoiding common pitfalls and implementing proactive measures.
Joyce Beseke, home care provider services representative for Blue Cross Blue Shield of the National Capital Area (Blue Cross) in Washington, DC, and representatives of Bayada Nurses in Morristown, NJ, recently outlined actions which will increase the likelihood of clean claims and faster payments:
• Check eligibility.
• Obtain pre-authorization (when required).
• Determine benefit limitations.
• Confirm coverage criteria.
According to Beseke, verifying a member’s eligibility is particularly important for services that do not require pre-authorization, because this may be the agency’s only contact with the patient’s managed care plan before rendering services. And while a provider may determine that a member’s coverage pays for the services in question, they sometimes fail to uncover benefit limitations. For example, a member may be eligible for private duty but only for two hours daily. The plan’s criteria for coverage is also important. Members may fall into different coverage brackets depending on whether they meet the plan’s homebound criteria.
At Bayada, RN clinical coordinators receive managed care referrals and basic insurance information such as the case manager’s authorization and covered member’s identification number. Insurance verification staff subsequently confirm the member’s eligibility, benefit limitations, and coverage parameters with the payer’s verification division. This check and balance system often thwarts potential problems. For example, a case manager may make a home health aide referral, but Bayada may then discover that home health aide services are not a covered benefit.
In this situation, a Bayada clinical coordinator contacts the referring case manager who either overrules the benefit limitation or cancels the referral, says Melissa Burnside, managed care office director. Because of such potential discrepancies, insurance verification should occur before service starts, preferably the same day of the referral.
Convenience, communication help
One great way to meet case manager communication expectations is to establish a managed care service function to guide your follow-up activities.
Follow-up is important for any pre-authorized service and is the only way case managers can update authorizations to reflect changes in a patient’s condition, but the appropriate level of communication varies between case managers and companies.
When Bayada lands a new contract, Burnside speaks directly with case managers to determine their communication expectations. Some prefer voice mail updates; others want faxed summaries; still others want faxed copies of nurses notes. Bayada clinical coordinators are expected to update all cases according to case managers’ stipulations.
Bayada established a managed care office in 1995 to better serve managed care clients. Its 12 RN clinical coordinators work in three teams which each handle an average of 12 managed care organizations. Each four-member team includes at least one pediatric and one critical care-experienced nurse. Clinical coordinators must have home care case management experience and receive an extensive one-month orientation in which they work side-by-side with an experienced coordinator. Burnside says that while the coordinators become intimately familiar with each organization’s contract terms, communication preferences and required billing, and documentation information, their real strength is knowing each case manager and meeting their individual needs. This translates into efficient service. She adds "case managers only have to tell us once" what they want.
All Bayada’s managed care referrals come through the managed care office, which insurance case managers reach via a toll-free number. Clinical coordinators use payer-specific referral forms to complete each intake. (See sample referral form, p. 12.)
The forms, which Burnside creates for each payer, include patient demographic and clinical data as well as payer billing requirements. Burnside says required billing information varies significantly between payers. For example, the payer for whom the sample referral form was developed requires the insured’s identification number and name on each claim. Another payer may want authorization numbers and the insured’s social security number. Payers also request different billing parameters. For example, some prefer Bayada’s gross charges on each claim, while others only want their contracted rates.
Although all referral information is entered in Bayada’s information system, clinical coordinators fax completed referral forms to the appropriate service office to expedite care delivery. Nurse managers in each of the company’s 29 service offices use the forms to flag service and communication requirements. They receive clinical updates directly from the field staff and pass the information on to Bayada’s clinical coordinators who, in turn, apprise case managers about each patient.
Linda Siessel, MEd, the division director, says Bayada added nurse managers to the communication chain after discovering that direct field staff-clinical coordinator communication was not speedy enough to meet case managers’ expectations. Though they often provide care themselves, the nurse managers can more readily contact and be contacted by clinical coordinators than field staff. To further facilitate timely updates, twice-weekly, Bayada’s managed care office also issues computer-generated pending authorization reports.
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