Being creative when benefits are maxed out
Look for alternatives to traditional care
When patients’ benefits have been maxed out or are close to being maxed out, case managers need to be creative with discharge planning, experts say.
If case managers know ahead of time that patients have used up their home health or physical therapy benefits, they can make sure patients and their family or caregivers receive enough education in the hospital to meet the patients’ needs at home, says Patricia Hines, RN, PhD, vice president of The Camden Group, a Los Angeles healthcare consulting firm. If there is a gap, look for resources that can help with the care, Hines says. For instance, if the physician says the patient needs 30 days of inpatient rehab and the patient is covered for only 20 days, see if outpatient or community-based rehab will suffice for part of the time.
Look for community-based programs, charity clinics, or programs that charge on a sliding scale and refer patients to them for post-acute care, she says. If a patient’s insurance doesn’t pay for medication, call on the social worker to identify medication assistance programs, Hines suggests.
Remember that when you are talking to insurance companies, "no" doesn’t always mean "no," says Catherine M. Mullahy, RN, BSN, CCRN, CCM, president and founder of Mullahy and Associates, a Huntington, NY-based case management consulting firm.
If you talk to the right person at the health plan, there may be room to negotiate benefits, Mullahy says. When you call the insurance company, you may be talking to an administrative assistant with no medical background who merely reads the benefits manual. Ask to speak to a case manager, and if "no" continues to be the answer, ask for the medical director, Mullahy advises. If that still doesn’t work, ask your physician advisor to call the medical director, she says.
A lot of health plans, particularly older plans, do not mention newer settings, such as subacute facilities, Mullahy says. "If a patient needs a service that’s not mentioned in the benefits book, you may need to investigate more closely," she says.
In addition to providing their own coverage, some insurance plans also administer services for self-funded employer plans, and in those cases, it’s the employer who can make a decision to cover a service, she adds.
Keep in mind that patients may be beneficiaries of several different plans and make the effort to find out, Mullahy says. A patient may be a veteran, have a work-related injury, or be a dependent on a spouse’s plan, she adds.
Sometimes, there’s no easy solution, says Brenda Keeling, RN, CPHQ, CCM, president of Patient Response, Inc., a Milburn, OK-based case management consulting firm. For instance, if patients need a skilled nursing stay but don’t have skilled nursing benefits, the choices are to keep the patient in the acute care hospital or send them home with outpatient services, such as home health, or pay out-of-pocket for skilled services. "Patients may be too sick to go home but not have home health benefits. This puts the patient and the facility between a rock and a hard place," Keeling says.
