Knowing benefits helps patients make choices
Few patients know what their plans will pay
When BK Kizziar, RN-BC, CCM, was in the hospital following surgery, a case manager walked into her room the day before discharge and asked whether she wanted to go to an acute rehab facility or have physical therapy sessions at home.
Kizziar, owner of BK & Associates, a Southlake, TX, case management consulting firm, asked what her insurance would cover and was surprised to hear the case manager say, "I don’t have any idea. Someone else deals with that. Just tell me what you want and I’ll set it up."
"I knew what my benefits are, but another patient might have chosen acute rehab and ended up with a huge bill if the health plan didn’t cover it. Patients should be able to make decisions about their post-acute care, but if case managers don’t give them the information they need to make informed decisions, they may make a decision that has a big financial impact," Kizziar says.
Part of being a case manager is knowing what you have to work with when you develop a treatment plan, she says. "It may not be the case manager’s job to speak to patients about finances, but it is their responsibility to know what the benefits are so the patient and family can take into account what is covered and what their out-of-pocket expenses will be when they choose post-acute services," she says.
Patients tend to think that if they’ve been paying for benefits, the plan will pay for whatever the doctor orders, points out Catherine M. Mullahy, RN, BSN, CCRN, CCM, president and founder of Mullahy and Associates, a Huntington, NY-based case management consulting firm.
"Very few people know what their benefits are. They know they have insurance, but they don’t know the copays or exclusions," Mullahy says.
Ideally, identifying patient benefits is a clerical task done at registration and forwarded to the case manager, Kizziar says. "That way, case managers are forearmed with the information when they see the patient and family for the first time. As the patient progresses and the case manager begins to create the discharge plan, having that information helps them understand what the patient’s benefits will allow them to do," she says.
Case managers should ask their hospital’s finance office to provide them with a managed care matrix that spells out what each payer will cover, suggests Brenda Keeling, RN, CPHQ, CCM, president of Patient Response, Inc., a Milburn, OK-based case management consulting firm. "This way, case managers can see at a glance that a payer won’t cover a stay in a long-term acute care hospital but will pay for skilled care and use that information to develop a treatment plan," she says.
If you can’t get a managed care matrix from the chief financial officer, create your own, Keeling says. Make a notation in a notebook of your experiences in getting certain benefits covered by specific payers and create a spreadsheet, she says.
"If case managers aren’t cognizant of the patient benefits and the number of days covered, they are jeopardizing patient rights and putting them at risk for out-of-pocket expenses," Keeling says.
Another way to find out benefits is by accessing the insurer’s patient portal or by asking family members to bring in the patient’s benefits book, Kizziar says.
Find out what post-acute services the physician thinks the patient will need and educate the family on what the insurance provider will pay and what their responsibilities will be. Give patients their options, along with what insurance will cover, Kizziar says.
Before you give patients a list of post-acute providers, find out if the providers are in the patient’s insurance company’s provider network, she suggests.
If the patient is a Medicare beneficiary, you still need to know whether it’s traditional Medicare or a Medicare Advantage plan, what the patient’s Medicare supplement plan, if any, will cover, and how much of the patient’s benefits have been used, she says.
"Very few people on Medicare understand that benefit. They know they have insurance but, in fact, there are limits," she says. "Many case managers don’t know what the Medicare copay is or what the patient will have to pay if he receives observation services versus being admitted as an inpatient. That hasn’t been case management’s focus, but it should be," she says.
