Can private duty, Medicare intake be linked?
It’s possible, but staff training is the key
Intake staff are your organization’s senior diplomatic corps, interacting with all existing and potential players in your home care sphere of influence. They run interference between and finesse relationships with physicians, payers, field staff, and clients; bundle disparately received intelligence into cohesive referrals; and know the rules and regulations governing your operation.
In the private duty world order, they are also promoters and negotiators, wooing customers by talking up your clinical expertise and service commitment while bargaining over the price and service array. And their actions play a large role in your organization’s success: One communication slip can make an indelible impression on unforgiving referral sources.
With so much at stake, having the right intake staff is critical. But the certified and private duty sides of the business each require different skills. Certified operations demand intimate familiarity with regulations and given fairly clear-cut Medicare coverage, less focus on benefit calculations and payment arrangements, while private duty requires great flexibility and an inexhaustible attention to verification and payment. "Medicare and managed care referrals are business-to-business exchanges, whereas private pay is usually a customer service transaction," according to Stephen Tweed, CSP, principal with Tweed Jeffries, a health care strategy firm based in Louisville, KY.
"There is a dynamic tension between the rules and regulations for both Medicare and insurance and the need for customer service," says JoAnne Ruden, MPA, RN, president and chief executive officer of the Visiting Nurse Association of the Delaware Valley in Trenton, NJ.
Such different requirements may lead providers to believe that it is best to separate certified and private duty intake functions, but that is not necessarily the case, according to sources. "A central intake, done properly, is a big benefit. But it’s hard to help people see both sides," says Nancy Woods, RN, specialty services director for Chattanooga, TN-based Contin-U-Care Home Health.
"There’s not an easy answer [to the best intake configuration]," says Ruden. "A lot depends on the manager [and whether] she is extremely market-oriented. A separate department for private duty may be ideal, but do you have the business for that and a seamless system to transfer between different functions? There is no magic bullet, no model for everyone. You have to consider your organizational culture and service delivery," she continues.
Some points to consider to ensure good intake operations include:
• Decide which services you will offer.
Providers just now moving into or with a small existing private duty business should first carefully evaluate the services they expect to provide, according to Linda Nelson, president of Help Source, a home care business consulting firm located in Wichita Falls, TX. Necessary clinical, intake, and other support functions flow from that analysis. For example, a pediatric managed care niche and hospital sitter services, with late night referrals and quick turnaround time, each demand different service structures and intake requirements, she explains. (See related article on private duty expansion strategies, p. 163.)
After identifying program expansion targets, determine anticipated operating expenses and develop a budget. Nelson recommends a minimum 10% net income target. Use the budget and profit goal to back into private duty rate sheets, she advises.
• Chose the right staff.
The program manager and a scheduler may be the only private duty administrative staff initially. So choosing the right manager is key, sources advise. "Look for an RN with a background [in the planned service] who understands that market — not Medicare! And she must have a sales heart," Nelson recommends. Like her private duty counterpart, the intake manager should also be sales- and customer service-oriented, sources advise.
Depending on the size of your operations and the services you offer, you may elect to have a separate private duty intake function. Particularly for personal care services, "the RN or director needs to be involved, but a clerical person can do it at the beginning," Britt says. The key is knowing what to ask, learning as much as possible, and bringing the nurse into the equation at the right time, she adds.
Whether or not you separate certified and private duty functions, training is essential, sources report.
Certified intake staff can learn private duty, according to Nelson. "You [just] have to make them believe [they] can do it. With Medicare more utilization-oriented, a Medicare-managed care crossover is probably OK now," she says. Still, some individuals may not have the right combination of sales savvy, detail orientation, people skills, and regulatory know-how to succeed. Personality profile tests may help identify those with the right stuff, she suggests.
• Explain expansion, costs.
Start training by having staff understand both the importance of expanding into private duty and your rate structure. "They have to understand why it costs so much when you pay [paraprofessional] staff so little: the workers’ compensation, malpractice, on-call expenses, etc. You have to go through it or else they’ll sabotage it because they think you’re overcharging," Nelson explains.
• Develop a service philosophy.
"You have to develop a service philosophy," Ruden advises. "It’s a continuous education with staff that [even] Medicare clients have choices and people are shopping." Customer service, phone courtesy, and sales training are the cornerstones of intake training, sources advise. If either sending staff to sales seminars or hiring a sales consultant are too costly, consider using training tapes to impart critical sales techniques, Nelson advises.
• Learn to ask the right questions.
Learning the nuances of private duty verification and negotiation come next. "The No. 1 mistake a lot of people make is they don’t call the insurance company at the beginning and find out [exactly] what the coverage is," Alisha Britt, training specialist at HelpSource explains. Staff tend not to ask the probing questions needed to get clients all the services they are entitled to and the company promptly paid, she explains.
For example, upon learning that a potential client is allowed 24 visits per year, some intake staff "will say OK. Thank you,’ and hang up, but they fail to get the insurance company’s definition of a visit. I’ve seen it range from one to eight hours," Britt notes.
Other common oversights include not determining whether a Medicare denial is necessary before private billing, and what billing forms are required. "You have to ask [the payer]; they won’t tell you," she adds.
(See sample reimbursement information form, p. 160.)
Intake personnel must also learn to work the insurance company’s system. For example, "with limited home health benefits, you can ask for the case management RN. [Then] it’s a whole new world. They care about the patient, [but] many people don’t know that you can do it," Britt explains.
• Provide negotiation training.
While it is important that intake staff understand the payer’s organizational and procedure maze, they must also know what to place on and remove from the negotiation table. "Private duty costs [can be] prohibitive, and [you have to be able to ask] What can we do [to work with the client]?’ You can put an option plan on the table and combine home health, DME, infusion, and a little private duty and help come up with something that meets client needs and preserves the referral," Wood explains.
"Unfortunately, people get intractable with their experience and background and for example, they may turn down a losing home health referral when you could do the patient’s associated DME. You have to look at the overall organization. If one program gets $10 and the other loses $5, you’re still better off," she continues.
Be prepared to bargain
If a client says I can’t afford that,’ staff should be prepared to bargain, according to Britt. "Just say We can always negotiate. Can I call you back in 15 minutes after I check with my administrator?’ You may not be able to give them [exactly] what they want, but even a 75 cents per hour reduction sounds better," she explains.
As very knowledgeable generalists, intake staff should be trained to think on their feet and know when to call in reinforcements. Scripts that outline responses to common private duty-related service calls help, but "some of it is trial by fire," Nelson says. Staff should learn to "never say never. If they can’t think of anything else, they should say I need to check with the nurse in charge of that area and call you back,’" she continues.
• Learn good listening skills.
Part of the art of private duty intake is learning as much about the potential client’s needs as possible while talking on the phone. Using one intake form for all patients, regardless of payer or requested services, may help intake staff walk through a series of discovery questions, Britt says. (See sample service request form, p. 161.)
Imagine you’re talking to your grandmother
During role-playing exercises, "I tell people Assume it’s your grandmother you’re setting up services for. She’s not eligible for Medicare but needs help.’ Your voice softens, and it leads you to understand what they’re in need of and to ask questions to determine needs," she adds. "You also need to make your language simple and easy to understand; remember, they’re not clinicians."
While it’s important to set up an intake system that doesn’t rely on the private duty expert, even the most knowledgeable person may not be able to see a potential client’s needs during a phone call. Train staff to explain that a referral phone call does not necessarily equal an admission. Consider offering free-of-charge assessment visits for potential self-pay clients, Britt suggests.
Woods agrees. "Even if you don’t get paid for that visit, its better than taking on a case and having problems later on," she says.
• Assess performance.
Training intake staff "can’t be a one-shot deal," adds Ruden. "You have to develop a feedback loop" to measure their effectiveness. Use a log to track inquiries that become new business, she says.
"You have to drive customer service both motivationally and through performance," Nelson agrees. She recommends testing your staff’s customer orientation and grace under fire by arranging a mystery shopper to call every quarter with a complicated service request. Offer a bonus to the person who best meets the customer’s needs.
No matter which intake configuration you choose and how much training you provide, staff should, above all, expect the unexpected. "It’s never the same. It’s different with every [referral], and [you just have] to ask a lot of questions and get to know the person as much as possible on the phone," Britt notes.
• Alisha Britt, Training Specialist; Linda Nelson, President; Help Source, 909 Burnett, Wichita Falls, TX 76301. Telephone: (940) 322-3777. Web site: www.helpsource.com.
• JoAnne Ruden, MPA, RN, President and Chief Executive Officer, Visiting Nurse Association of the Delaware Valley, P.O. Box 441, Trenton, NJ 08603. Telephone: (609) 695-3461.
• Stephen Tweed, CSP, Principal, Tweed Jeffries, P.O. Box 24475, Louisville, KY 40224. Telephone: (502) 339-1600.
• Nancy Woods, RN, Specialty Services Director, Contin-U-Care Home Health, 806 Dodds Ave., Chattanooga, TN 37404. Telephone: (423) 624-4346.