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Cover pediatric underfunding with new services
Staff responsible for verifying insurance info
Not only do home health agencies with pediatric services face the daunting task of finding staff members qualified for pediatric patients, but agency managers also deal with reimbursement problems that don't exist for adult populations.
"Our biggest challenge is the fact that reimbursement amounts set by Medicaid, Medicare, and most private insurers, are based on adult care," says Wanda Stackpole, RN, vice president of Children's Homecare in Columbus, OH. Pediatric patients are not just smaller versions of adult patients, so home care staff members spend a lot of time justifying the costs for everything needed for patients, she says.
"Our patients are constantly growing and as they grow, their needs change," explains Stackpole. Equipment and supply sizes change as the child grows, so there is a need to acquire new equipment and supplies during the course of care, she says. Because adults don't change as frequently as children, it is important to document the reasons for changes thoroughly, she says.
Overhead costs for pediatric services are typically higher because you are providing a higher level of nursing care for most patients, says Stackpole. Infusion nurses must be able to calculate doses based on weight that will change from visit to visit, she points out. "We also have to be able to evaluate patients who cannot tell us how they are feeling," she adds.
The good news is that some states do have home health care waivers for medically fragile children, says Stackpole. It is important for a home health manager to thoroughly understand his or her state's standard home health benefit as well as any additional benefits that may be available to children, she adds.
It is also important to participate in negotiations with managed care companies, especially if your agency is part of a hospital or health system, and is typically included in the blanket contract, points out Stackpole. "Be ready to explain that you cannot safely save money by infusing a pediatric patient with a drip infusion as opposed to a pump, and that your nurses do need to use a variety of blood pressure cuffs because one size does not fit all," she says.
Evaluate new services
One way to cover the costs of care that is underfunded is to develop new services that generate revenue. "We have looked at a variety of services that can bring in money to underwrite unfunded care," says Stackpole. While she did evaluate the possibility of providing some adult care, that approach to new services was not taken, she says. "We decided that our expertise is in pediatrics and we needed to stick with what we know best," she says.
An example of adult care that her agency chose not to pursue was the antepartum care in a new mom and baby program, explains Stackpole. "While we were comfortable providing some of the postpartum assessments along with the newborn assessments, antepartum care was not part of our core competencies because it is adult care," she explains.
"For many years we've had a contract with the child protective services department in our area to provide an after hours nurse to conduct medical screenings for children that come into their custody in the evening," explains Stackpole. "This is a low cost service for us to provide because we already have nurses who are on call in the evenings, the screenings are not complicated, and the services are in line with our expertise," she adds.
Stackpole has also evaluated wellness programs such as assessment programs for high-risk infants. "It is important to know what is going on in the cities and counties in your service area," she suggests. There may be a health department that either wants to offer or is offering such a program but could use a community partner in the venture, she says. Identification of these opportunities is easier if the administrator and managers of the home health agency are involved in community organizations that relate to pediatric services, she points out.
Foundations and community grants do offer another source of funding but sometimes the grants are designed to address the needs of large populations, points out Stackpole. To find grants that may support efforts to address smaller, narrower niches of patients, look in your own community and within organizations for which your employees volunteer, she suggests. "Check out county, city, and state health department websites and state home health associations," she adds.
Evaluate your own data collection
In addition to looking for new ways to bring in revenue, it is also important to evaluate current practices to make sure you're collecting everything you should be collecting, points out Stackpole. "A couple of years ago we were losing a lot of money so we looked at every aspect of our operation," she says. Although as much information as possible was collected at the front-end of an admission, Stackpole's nursing staff was not involved in verifying information as visits were made. "Now, all nurses verify information as visits are made to make sure that we know about insurance changes," she explains. "This is very important in our state as families move from traditional Medicare to managed care," she adds.
At first nurses and other clinicians were not comfortable addressing financial issues but ongoing education and explanations of what the accurate information meant to the agency in terms of collecting proper reimbursement have eliminated the resistance, admits Stackpole. "The pharmacists in our infusion service were most resistant because they believed their focus should be on patient safety, proper dosing, and verifying prescriptions," she says.
Educational sessions for staff members addressed the importance of verifying information beyond the initial assessment visit, says Stackpole. "Long-term patients are at highest risk of changing insurance and it is not uncommon for us to have some patients in our service for years," she adds.
The importance of accurate documentation, especially for long-term patients who undergo many changes in equipment and medication needs, was another point covered in staff education, says Stackpole. "It is essential that the medical necessity for the change be clearly described in the documentation to ensure a clean claim," she explains.
Telling employees about the need to verify coverage and document accurately was not the only step Stackpole's agency took to underscore the importance of these jobs being undertaken by all staff. "We incorporated these activities in our job descriptions and job competencies," she says.
"As pediatric providers, it is easy for all of our staff members to get caught up in the emotional side of caring for little ones," admits Stackpole. She adds, "Our emphasis on everyone taking responsibility for making sure we were reimbursed properly helped all patients because it ensures that we have funds for patients who may not have coverage."
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