Education helps payers accept day program

Case managers are sold on the results

Convincing payers to reimburse for the day treatment program at Columbia St. David’s Medical Center takes a lot of education, but once case managers see the results, they’re usually sold on the program, says case manager Shaley vonDoenhoff, LMSW.

"We do so many things that are not traditional that it requires a lot of education. But once the external case managers see that our clients make gains quicker than in other programs, they realize our innovations are very therapeutic," she says.

When a patient is referred to the St. David’s day program, vonDoenhoff sends the payer an initial explanation of the program, including details about the facility and the purpose of the therapy. The program is covered by Medicare Part B.

Some of the questions she tries to answer ahead of time include the following:

o Why are some occupational therapy tasks, such as cooking, therapeutic? She points out that the occupational therapist may be working to help the stroke patient regain use of an arm and practice speech and cognitive exercises at the same time.

o What is therapeutic recreation, and why is playing games therapeutic? For example, she shows that playing golf increases ambulation and balance and helps patients regain the use of their muscles.

o Why is hippotherapy (therapeutic horseback riding) beneficial?

"Once the outside case managers learn our program and see how the clients benefit, they fight for their clients to come here. It takes work to get them to that point, however," she says.

After a patient is accepted into the program, vonDoenhoff compiles a summary from the biweekly team conference and sends it to the insurance case manager, the referring physician, and the family.

Going out of contract

Day treatment is rarely covered benefit by some insurance companies, but St. David’s has been able to persuade some companies to go out of contract and provide the service.

"When you’re dealing with smart people, they see that it’s going to save them money in the long run," she says.

If it looks like the insurer won’t fund the treatment program or if a patient has limited benefits, she always asks for a case manager to be assigned. "Once case managers are educated, they will advocate for their clients."

If an insurance company initially refuses pay for the program, she also tries get the family and physicians involved in getting approval. "If the family and doctors get involved, it’s amazing how much more you can get from an insurance company. Letters of medical necessity have a lot of pull since the [Texas] Legislature passed a consumer protection law that allows patients to sue if an HMO refuses to reimburse for a procedure that is deemed a medical necessity," vonDoenhoff says. "That has made a night and day difference in approvals."

The type of billing depends on what the insurance company will pay. For example, the payer may want to be billed for a certain type of therapy a certain number of times a week. Others will pay for all the services but want a flat per diem rate.

Sometimes the team recommends more treatment than the insurance company is willing to pay. Then St. David’s staff work with the family to come up with a solution: Some families pay for part of the therapy, for instance, or seek other funding such as help from the Austin office of the Texas Rehabilitation Commission.