Case Management 101 Reimbursement, Levels Of Care,

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Case Management 101Reimbursement, Levels Of
Care, Disposition Planning
For the Medicine Housestaff July 11, 2008
Beverly Wagner, RN CCM Clinical Care Management
Educator
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Reimbursement 0.5
The Tip of the Iceberg
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Deductible

• 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

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Co-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

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Co-insurance

• Percentage amount per service the patient must
  pay
• Usually in addition to deductible and co-pay

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Footing the Bill

• For one healthcare encounter, a patient may have
• Deductible (up front)
• Co-pay (fixed)
• Co-insurance (percentage)

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An Outpatient Example

• For outpatient care a Medicare beneficiary in
  2008 is responsible for
• Calendar year deductible 135
• Co-insurance 20 of approved charges

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An 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

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Benefit

• 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)

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Medical Necessity

• Determination that service is
• Appropriate
• Clinically necessary
• Accepted as standard of care
• Not experimental
• Not custodial
• No standard definition or concurrence

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When 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

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Bed Status 1.0
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Bed Status Options

• Extended Recovery
• Observation
• Inpatient

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Extended 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

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Observation

• 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.

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Observation Ends When

• EITHER
• The patient is appropriate for discharge
• OR
• Inpatient status is justified
• Observation duration is NOT dependent on a time
  frame

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Inpatient

• May be planned or unplanned
• Always requires a licensed bed
• Requires criteria justification or second level
  approval to bill

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Considerations 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

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So, 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.

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So, 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

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So, What Should I Do?

• Document with specificity (not necessarily more
  words)
• Baseline
• Risk
• Intent
• Plan
• Co-sign bed status conversion orders
• Stay tuned

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Disposition Levels of Care
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Headed for Another Hospital
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LTACH 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

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LTACH Considerations

• Must have high level of acuity
• Anticipated LOS25 days
• Not all insurance covers
• Identifiable disposition post LTACH

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Acute 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)

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Department of Corrections

• Daily physician rounds
• 24/7 nursing
• NG, Foley
• IV meds
• Wound care
• Limited diagnostics
• Good compliance

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Placement (aka Nursing Home)

• Skilled Nursing Facility (SNF)
• Assisted Living Facility (ALF)

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Skilled 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)

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Skilled Rehabilitative Needs for SNF

• Disciplines
• PT
• OT
• Speech
• Frequency
• Combined total 5x/wk

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Medicare Covers SNF, IF

• Skilled needs
• Qualifying hospital stay
• Medicare certified facility

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Qualifying 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

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Medicares 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).

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But 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.

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Assisted 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

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ALF Services

• Supervison for safety
• Hygiene and grooming
• Nutrition
• Transfer assistance
• Medication supervison
• Socialization

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ALF Reimbursement

• NC Medicaid
• Some Long Term Care policies
• Self Pay
• ALF is not covered by employer insurance policies
  or Medicare

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Is it a SNF or ALF?

• Separate licensure and staffing
• Some facilities offer both levels of care
• Your Care Coordinator or Social Worker can advise

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Going Home
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Home Infusion

• Medications and/or fluids
• Patient/caregiver(s) willingness to learn and
  participate
• Coordination with 2 vendors
• Home Health
• Pharmacy

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When Home Infusion Isnt An Option

• Barriers
• Insurance coverage
• Situational
• Social
• Alternatives
• SNF
• LTACH
• Home infusion is NOT covered by Medicare!

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Home 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!

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Home Health Appropriateness

• Home environment can support care needs
• Patient is homebound
• Patient/caregiver willing able to learn care
  needs

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Homebound 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

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Home Health Providers

• Nursing (RN)
• Physical Therapy
• Occupational Therapy
• Social Work
• Respiratory Therapy
• Aide
• only while an RN or PT is involved

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Outpatient Care Appropriateness

• Clinically stable
• Transportation available

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Planning 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

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CCM 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

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Case 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

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Who 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

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Questions?