Making insurers want to pay for home care

Work closely with case managers

Getting health plans to reimburse you for home care services is "an uphill battle," but it can be done, says Lynn Thomas, BSN, Phn, home health liaison at Mary Birch Hospital for Women in San Diego. Thomas has been involved with home care for more than six years, and she is steadily convincing each insurer doing businesses with her hospital to pay for home care.

Here’s her strategy:

• Establish a rapport with the case managers for each insurer.

• Educate the case managers about what home care nurses can provide and the potential for cost savings.

• Work out a plan to prove the benefits of home care. This can be as simple as deciding on an outcome measure and keeping detailed records about it for a short time.

Thomas says her outcome measure is the prevention of preterm labor. She was able to show that home care nurses can keep women out of the hospital until they are ready to deliver, and provided examples to the insurers showing a cost savings of $35,000 to $50,000 per case.

Hospital officials couldn’t be happier to get women into the home care program. Insurers typically pay only about $225 per day for "administrative days" in the hospital (when the woman is merely observed), but those beds cost about $1,200 per day, Thomas says. Conversely, home care can be provided for about $65 per day, and some HMOs reimburse from $85 to $125 per day, she adds.