Title: Case Management 101 Reimbursement, Levels Of Care,
1Case Management 101Reimbursement, Levels Of
Care, Disposition Planning
For the Medicine Housestaff July 11, 2008
Beverly Wagner, RN CCM Clinical Care Management
Educator
2Reimbursement 0.5
The Tip of the Iceberg
3Deductible
- An amount the patient must pay before the payer
makes any payment to the provider - Usually fixed amounts on a yearly basis
- May have individual and family amounts
4Co-pay
- Fixed amount per service the patient must pay
- Provider is responsible to collect
- Patient may be incentivized to lower cost options
- Network providers
- Generic medications
5Co-insurance
- Percentage amount per service the patient must
pay - Usually in addition to deductible and co-pay
6Footing the Bill
- For one healthcare encounter, a patient may have
- Deductible (up front)
- Co-pay (fixed)
- Co-insurance (percentage)
-
-
7An Outpatient Example
- For outpatient care a Medicare beneficiary in
2008 is responsible for - Calendar year deductible 135
- Co-insurance 20 of approved charges
-
-
8An Inpatient Example
- For an inpatient stay, a Medicare beneficiary in
2008 is responsible for - Benefit period deductable 1024
- Co-insurance
- Days 1-60 none
- Days 61-90 256 per day
- Days 91-150 512 per day
- Days 151 All costs
-
-
9Benefit
- A service covered by the insurance plan, payable
to the insured - May require prior approval
- May have limits on
- Who can provide the service (network)
- How many services can be provided ( of visits,
days, etc)
10Medical Necessity
- Determination that service is
- Appropriate
- Clinically necessary
- Accepted as standard of care
- Not experimental
- Not custodial
- No standard definition or concurrence
11When Medical Necessity and Benefits Collide
- Service may be Medically Necessary but not be
covered by Benefits - Examples
- Wound infection following cosmetic surgery
- Gunshot wound sustained while robbing a bank
12Bed Status 1.0
13Bed Status Options
- Extended Recovery
- Observation
- Inpatient
14Extended Stay/Recovery Defined
- For planned post-operative or procedure recovery,
typically 4-6 hours - For short stay services following uncomplicated
treatment such as chemo or infusion therapy
15Observation
- A period of time to determine the need for
- further treatment, or
- an inpatient admission.
- A patient in observation may
- improve and be released, or
- be admitted as an inpatient.
16Observation Ends When
- EITHER
- The patient is appropriate for discharge
- OR
- Inpatient status is justified
- Observation duration is NOT dependent on a time
frame
17Inpatient
- May be planned or unplanned
- Always requires a licensed bed
- Requires criteria justification or second level
approval to bill
18Considerations For Inpatient Approval When
Criteria Are Not Met
- Severity of signs and symptoms
- Clinical predictability of adverse events
- Need for urgent diagnostic studies to guide
treatment decisions - Baseline co-morbid conditions pose a safety risk
to deliver care in an outpatient setting
19So, Who Decides The Status?
- Federal Government
- Centers for Medicare and Medicaid Services (CMS)
Policy - Office of the Inspector General (OIG) Audits
Retractions - Evidence based criteria sets
- InterQual
- Expert Physician Advisors
- Executive Health Resources (EHR)
- CCM assesses each case per current criteria and
policy directives. Questionable cases go to EHR.
20So, Why Should I Care?
- Physician Reimbursement tied to Hospital
Reimbursement (New!) - RACs and MACs
- Recovery Audit Contractors (hospital)
- Medical Administrative Contractors (physician)
- Mismatched status
- Upcoding
- Profiling and Credentialling
21So, What Should I Do?
- Document with specificity (not necessarily more
words) - Baseline
- Risk
- Intent
- Plan
- Co-sign bed status conversion orders
- Stay tuned
22Disposition Levels of Care
23Headed for Another Hospital
24LTACH Long Term Acute Care Hospital
- Physician assessment/intervention daily
- Respiratory interventions gt/ 3/24h
- Skilled nursing gt/ 6.5h/24h
- Better outcomes in some areas
- Typical needs and services
- Respiratory failure with mechanical
ventilation/weaning - Multisystem failure
- Complex infectious disease/sepsis
- Invasive hemodynamic monitoring
- Complex wound care
- Dialysis
25LTACH Considerations
- Must have high level of acuity
- Anticipated LOS25 days
- Not all insurance covers
- Identifiable disposition post LTACH
26Acute Inpatient Rehabilitation Hospital
- S/P Acute Event or Illness
- Need for rehab is primary reason for admit
- Ability to learn
- Identified disposition
- Can tolerate/participate in
- 3hrs/day therapy, 5d/wk
- 2 or more disciplines (PT/OT/ST)
27Department of Corrections
- Daily physician rounds
- 24/7 nursing
- NG, Foley
- IV meds
- Wound care
- Limited diagnostics
- Good compliance
28Placement (aka Nursing Home)
- Skilled Nursing Facility (SNF)
- Assisted Living Facility (ALF)
29Skilled Medical Needs for SNF
- Maximum ADL assistance (total care)
- Complex bladder/bowel regimens
- Sub-acute rehabilitation
- IV/SQ medication administration
- Wound management
- Tube feedings and care
- Chronic ventialtor care (limited facilities)
30Skilled Rehabilitative Needs for SNF
- Disciplines
- PT
- OT
- Speech
- Frequency
- Combined total 5x/wk
31Medicare Covers SNF, IF
- Skilled needs
- Qualifying hospital stay
- Medicare certified facility
32Qualifying Hospital Stay
- Inpatient criteria met (InterQual)
- Criteria met each of three consecutive days
- The three consecutive days are within the last 30
days (not necessarily the current hospital stay) - only your Care Coordinator knows for sure
33Medicares Placement Expectation
- When
- Patient is medically ready, and
- At least one bed offer is made from a certified
facility - Then
- On the day the first offer is made,
- The patient is expected to accept from available
choice(s).
34But I dont want to go there
- When
- A patient refuses to accept a placement offer
from a Medicare certified facility - Then
- The patient is responsible for charges associated
with continued hospital stay. - subject to Important Notice from Medicare
requirements and appeal process. No automatic 3
day grace period.
35Assisted Living Facility
- Care is primarily custodial
- ALF becomes the patients home (home health can
come in) - Patient requires frequent but minor assistance
with - ADLs
- Bowel/bladder incontinence
- Meal preparation
36ALF Services
- Supervison for safety
- Hygiene and grooming
- Nutrition
- Transfer assistance
- Medication supervison
- Socialization
37ALF Reimbursement
- NC Medicaid
- Some Long Term Care policies
- Self Pay
- ALF is not covered by employer insurance policies
or Medicare
38Is it a SNF or ALF?
- Separate licensure and staffing
- Some facilities offer both levels of care
- Your Care Coordinator or Social Worker can advise
39Going Home
40Home Infusion
- Medications and/or fluids
- Patient/caregiver(s) willingness to learn and
participate - Coordination with 2 vendors
- Home Health
- Pharmacy
41When Home Infusion Isnt An Option
- Barriers
- Insurance coverage
- Situational
- Social
- Alternatives
- SNF
- LTACH
- Home infusion is NOT covered by Medicare!
42Home Health Care
- Post-discharge follow up for
- Medication administration (parenteral)
- Wound/drain management
- Clinical assessment
- Therapy (PT/OT/ST)
- Hospice/palliative care
- Visits
- typically 1-3 times per week
- Initial assessment visit
- Subsequent visits approx 1 hr each
- Primary focus is to TEACH, not perform!
43Home Health Appropriateness
- Home environment can support care needs
- Patient is homebound
- Patient/caregiver willing able to learn care
needs
44Homebound Status
- Leaving home takes considerable and taxing effort
- May leave home for medical care
- May leave home for infrequent, short term
non-medical reasons, such as a haircut or
attendance at a religious service - Adult day care does not preclude homebound status
- www.medicare.gov. Medicare and Home Health Care,
p 11
45Home Health Providers
- Nursing (RN)
- Physical Therapy
- Occupational Therapy
- Social Work
- Respiratory Therapy
- Aide
- only while an RN or PT is involved
46Outpatient Care Appropriateness
- Clinically stable
- Transportation available
47Planning for Disposition
- Keep your Case Manager in the loop
- Define care needs
- Assess level of care options
- Explore reimbursement realities
- Dont promise what cant be delivered
- Keep a backup plan in mind
- Acceptable vs Optimal
48CCM Case Manager Roles
- Every patient in a bed has an assigned Care
Coordinator (CCC) - UM
- Some discharge planning
- Some patients have a Social Worker (SW)
- Complex/Psychosocial cases
- Legal issues
- Some discharge planning
49Case Manager Coverage
- Inpatient CCC/SW
- M-F business hours
- On call SW at night for emergencies
- ED CCC
- 24/7 coverage
- ED SW
- M-F 8am-8pm weekends 8am-5pm
- Limited holiday/weekend coverage during business
hours
50Who What Should My Case Manager Know About?
- Failed discharge plans
- Post-discharge needs (inc transportation)
- Anticipated change in level of care at discharge
- Patients with current services from
- Home Health
- Dialysis
- Social Services
- Patients from facilities
- Group homes
- Assisted Living
- Skilled Nursing Facilities
- Department of Corrections
51Questions?