Experts: Know your patients’ benefits and work to conserve them
Executive Summary
Case managers should know their patients’ insurance benefits and out-of-pocket expenses when they develop a discharge plan to make sure the patient can afford the plan they are putting in place.
• Take policy limitations into account and preserve benefits for their future needs.
• Look for community resources such as medication assistance plans and clinics that charge a sliding scale when patients don’t have coverage for needed services.
• Make sure patients and family members understand the benefits when they make choices about post-acute care.
Look beyond the current episode of care
If you don’t take patients’ benefits into consideration when you create a discharge plan, you are doing a big disservice to the patients and to the hospital if patients are readmitted because their discharge plan failed, experts say.
It’s possible for a case manager to be coordinating care for several patients with the same diagnosis, all of whom have different insurance coverage with benefits that affect the discharge plan, points out BK Kizziar, RN-BC, CCM, owner of BK & Associates, a Southlake, TX-based case management consulting firm.
"If case managers don’t know the difference in what payers cover, they could put together a treatment plan that looks great on paper but isn’t realistic," she says. "The choice of post-acute services is not just a medical decision anymore. It’s also a financial decision, and if you don’t know your patients’ benefits, you can’t develop a plan that will work for them. Case managers always should be aware of what services a patient’s insurance covers after discharge as well as while they are in the hospital."
"There’s no one-size-fits-all discharge plan, even for patients with similar conditions," says Catherine M. Mullahy, RN, BSN, CCRN, CCM, president and founder of Mullahy and Associates, a Huntington, NY-based case management consulting firm.
"The plan should be determined by what kind of benefits each patient has. Just as you can’t pay your bills without knowing how much is in your checking account, you can’t develop an effective care plan unless you know what dollars you patient has for the plan you’re putting in place," Mullahy says.
Physicians may think that if patients have insurance, they have carte blanche to refer them for any service. Case managers need to be cognizant of patient benefits and point out when something the physician orders isn’t covered. The case manager often functions as a negotiator between patient, physician, and insurer to find alternatives, says Brenda Keeling, RN, CPHQ, CCM, president of Patient Response, Inc., a Milburn, OK-based case management consulting firm.
The Case Management Society of America and the American Case Management Association standards say that case managers need to be advocates for their patients, and being good stewards of benefits falls under advocacy, says Patricia Hines, RN, PhD, vice president of The Camden Group, a Los Angeles-based healthcare consulting firm.
"Discharge plans can’t be based strictly on insurance. You have to do what is right for each patient. It’s often a balancing act between the benefit plan and the patient’s care needs," Hines says.
The best practice is for case managers to always be aware of patients’ benefits and take them into account when developing a discharge plan, Kizziar says. Explain the benefits to patients so they can understand what will be covered by insurance and what their responsibilities will be, she adds.
Patients’ benefits depend on the policies they have chosen, but most policies cover a limited number of therapy or home health visits a year, and if the patient uses them all up, he or she will have to forgo treatment or pay out of pocket, Kizziar says.
State Medicaid programs and Managed Medicaid plans have limits on the days they cover, and the number of days may vary by state, Keeling says. Traditional Medicare and Medicare Advantage also have limits, she adds.
Medicare allows patients 60 lifetime reserve days which can be used when the benefit days have been used up. Medicare allows 90 days per benefit period, Keeling says. A benefit period begins when the patient enters a hospital or skilled nursing facility and ends when the patient has been out of the facility for 60 days in a row, she adds.
"Case managers should work with their physician advisor to ensure that physician documentation and the treatment plan support medical necessity for admission to protest these Medicare reserve days and prevent patients from incurring unnecessary out-of-pocket expenses," she says.
Take the time to develop a plan that gives patients what they need now as well as conserving their benefits for their future needs, Kizziar says.
"Instead of having tunnel vision and dealing only with the present, case managers need to broaden their scope and be as conservative as possible, taking into account that the patients may need their benefits in the future," Kizziar adds.
If you have a patient with a chronic condition and it’s early in the year, try to conserve the visits in case the patient needs them later in the year, Hines says. For instance, if a patient is going to need long-term outpatient physical therapy and his or her plan covers only 20 visits a year, instead of recommending two visits a week, consider setting up just one visit a week with the patient doing exercises at home in between.
"Case managers need to remember that patients don’t have an unlimited amount of benefits. There is a bottom to that well," she says.
Even if patients have unlimited resources, it’s irresponsible to use it all, Mullahy says. "The health plan is insuring other patients and doesn’t have an unlimited amount of resources. Case managers should be good stewards of the pool of resources for everyone," she says.
Hospital Report blog
For further analysis and discussion of topics important to hospital professionals, check out Hospital Report, AHC Media’s new free blog at http://hospitalreport.blogs.reliasmedia.com/. Hospital Case Management’s executive editor Russ Underwood and associate managing editor Jill Drachenberg both contribute.
