Require inservice on rules of reimbursement
Require inservice on rules of reimbursement
Connecticut agency's staff gobbled up information
Medicare and other payers have a maze of rules for home care staff to navigate. How can they make it through the material without running into false turns and dead-ends? The answer, one education manager says, is in a heavy-duty inservice on the rules of Medicare reimbursement.
"For three hours, we grill them on payer source," says Kelly McCue, RN, education coordinator for Middlesex Hospital Home Care of Middletown, CT. The agency also has home care offices in Clinton and East Hadom and covers the eastern part of Connecticut.
Despite the dry nature of the material and the fact that the agency made its attendance mandatory, the staff have been enthusiastic, almost hungry for the information, McCue says.
The agency's employees are eager to know details about the regulations that govern their work, and they were the ones who asked for the inservice because they'd have so many questions each day about payer requirements, McCue adds.
"We're going into our fourth class, and I've never had so many people say, `I can't wait to hear more about Medicare,'" McCue says.
Also, the agency's documentation has improved considerably and has been turned in faster since the inservices, McCue says.
Now nurses understand why they have to do some of the seemingly nit-picking documentation tasks, and so they are complying more, she adds.
The inservice could be broken into two or more sessions because it probably will take several hours to present all the material. Middlesex Hospital Home Care included information about Medicare, Medicaid, commercial insurance, health maintenance organizations (HMOs), how to use different payers, nursing implications, billing, documentation, and the agency's tools. An exam is held at the end, and staff receive three hours of inservice credit for attending.
"We have different questions in every class, and then we research the answers and present them in the next class," McCue says, adding that they also send the staff written updates with the new information.
McCue held the inservice with the help of the agency's manager of billing, so they would receive both the nursing and billing components. Here are some of the topics they cover:
· Medicare program structure:
Medicare, Part A, is what pays for the hospital, acute services, skilled nursing visits at home, nursing aide visits at home, and up to 100 days of skilled care, McCue explains.
Medicare, Part B, covers the physician office, nonskilled visits, routine visits, durable medical equipment, and outpatient visits, such as visits to the physician's office.
· Nursing considerations:
"Nurses have to check the insurance card and find out if the patient has another insurance plan," McCue says.
So she suggests nurses ask patients whether their spouses work and if there might be a secondary insurance.
Also, if the patient has an HMO plan, then the nurse should call the insurance company and discuss the plan of care to see if that will be allowable. "The nurse has to discuss the plan of care with the HMO to see if they need to make the visit once or twice a week," McCue says.
"I've been doing this for 16 years, and this stuff is what nurses have been learning to do over the last five to six years," she adds. "This is a big part of their job now."
Nurses also may look for community services that will help patients. These might include senior centers, blood pressure clinics, cholesterol screening, and other free health care services.
· Communication with physician:
This is very important, especially when the physician's orders conflict with what the insurer will pay.
"Sometimes you have to negotiate the plan of care with the doctor and insurance company," McCue says.
Then, nurses at Middlesex Hospital Home Care document what the physician says and what the insurance company says. They also document all nursing visits, and they document each time they receive an authorization and update with the physician.
It requires nurses' constant action to make sure all visits are paid for and that the patient is receiving all the visits eligible under the insurance plan, McCue says.
· How billing works:
The agency's manager of billing describes the agency's step-by-step process of handling paperwork once a case enters the billing department.
Nurses can make billing employees' jobs easier by making sure their documentation is complete, McCue says.
Mistakes may be small but troublesome, such as forgetting to put a number or the letter A at the end of the Medicare number.
The billing manager also explained how time slips are recorded in the computer and how all visits need to be authorized with a paper trail.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.