Specialists increase managed care revenues

A little knowledge goes a long way

Whether your agency is small or large, chances are you’re being referred more patients from managed care companies.

Some agencies view managed care patients as more trouble than they’re worth because of increased documentation and hassles often associated with managed care organizations (MCOs). However, other agencies view these cases as opportunities for potential revenue sources.

Divide and conquer

Two experts say the best way for home care agencies to handle MCOs is to designate one employee as a managed care specialist or case management coordinator. This model relies on having one person develop rapport with MCOs and learn their lingo.

"I think even a small agency could and should do it by having someone, such as a supervisor, designated to do it," says Brenda A. Trask, RN, MSN, site visitor for the Community Health Accreditation Program, in New York City. Trask has spoken nationally on patient care in the new millennium, and formerly was the director of clinical operations for Inova VNA Home Health, in Springfield, VA.

Managed care specialists are the liaison between the staff and the managed care companies. Their role is to make sure communication flows smoothly and nurses and therapists know exactly what MCOs expect. Also, they explain to MCO case managers why a particular patient needs extra nursing or therapist visits.

Inova VNA Home Health began a managed care program in August 1997, eventually employing three managed care specialists. By 1998, the agency began to experience some positive outcomes, Trask says. For example, payers began to reimburse the agency a little faster, and there were fewer complaints from both payers and physicians.

"Mainly, we noticed our authorizations went through more smoothly, and there were fewer discrepancies on the billing side," Trask says. "We had fewer complaints from physicians because they were getting the services they ordered, and the managed care specialists were able to talk with physicians about different ways to get things done."

The program, which Inova VNA expanded since Trask left, will soon have nine case manager coordinators, who will handle all reimbursement issues except for regular Medicare cases, says Eileen L. Dohmann, MBA, RNC, executive director of Inova VNA Home Health, which has 270,000 visits a year with four offices that serve metropolitan Washington, DC, metropolitan Maryland, and northern Virginia.

Agencies need MCO revenues

Dohmann says it’s no longer an issue of whether the agency can afford to create these specialty positions: "You can’t afford not to do it."

Previously, Inova simply had each nurse deal with the MCOs that covered their particular patients. "On any given day, we could have 20 nurses calling managed care organizations," Dohmann says.

This created a lot of headaches. For example, a nurse might forget to obtain authorization for visits, and reimbursement was denied. In other cases, nurses might obtain authorization, but forget to tell the billing department that the visits were approved. In still other cases, the agency might have negotiated a certain rate with a MCO, but no one told the billing department what that rate was supposed to be.

Managed care specialists or case management coordinators handle all of the communication components; therefore eliminating most of these problems.

"It’s a coordination piece that is so difficult, and it’s very timely and expensive," Dohmann says. "But if you don’t [create those positions], you are effectively saying you don’t want that managed care business."

Inova has seen a steady increase of its managed care business since beginning the program. However, Trask says that trend was market driven and has only highlighted the need for managed care specialists. "The timing was right, and we were trying really hard to keep our focus on good patient care. As a result, it turned out to be good business," Trask explains.

Dohmann says the increased managed care business has helped the agency survive during Medicare’s implementation of the interim payment system. She says the coordinators could become experts on handling the prospective payment system when it is implemented.

"More of our referrals will be handled by those people who are very focused on how to maximize service for the patient and maximize reimbursement for the agency, while always maintaining that services provided are appropriate to the patient’s need," Dohmann adds.

Step up to the plate

Trask offers these guidelines to developing a managed care specialist program:

1. Focus on improving communications.

It’s easier for payers and home care agencies if they are talking with the same person each time a case is discussed. "We started with the idea that this was a communication role, and it’d be easier for the payers if they were talking to the same person each time — if the same person was keeping track of things," Trask says. "We knew we had a communication problem, and we were making sure that patients were getting services and were satisfied."

Payers also had a communications problem with physicians, who were frustrated because they could not understand why they were not receiving authorization for their orders, Trask recalls.

She suggests agencies select managed care specialists by looking for nurses who have good communication and strong organizational skills.

2. Describe managed care specialists’ duties.

The managed care specialist duties include:

• maintain continuity of care by making sure the staff uses the appropriate agency and community resources in planning care;

• coordinate authorization and communication between the payer and clinical teams;

• facilitate the agency’s compliance with external and internal clinical policies and company contracts;

• act as a resource to professional and paraprofessional staff;

• maintain the chronological documentation of these coordinated efforts in the patient’s history file.

The managed care specialist also oversees the cost-effective purchase of patient supplies and ensures that the agency uses the vendors that have a contract with any particular MCO.

3. Select quality monitoring areas for managed care.

Quality managers and managed care specialists monitor the following areas:

• number of retro-authorizations, successful and denied;

• number of authorizations vs. number of visits not made;

• number of recalls to clinical staff to obtain additional information to get authorizations;

• delays in authorizations greater than 48 hours;

• unbilled revenue;

• bad debt — visits made without authorization split out from Medicare.

The managed care specialist or quality manager can create a simple authorization tracking tool that includes six columns consisting of these categories: Patient name; patient ID number; payer; number of visits authorized; authorization period, and dates of visits.

Trask also suggests agencies create managed care reports for nurses and therapists. These reports explain exactly what the nurses and therapists need to report to the managed care specialist and when they should make verbal reports. (See description of nursing and therapy reports, p. 23.)

4. Have managed care specialists educate staff on MCOs.

Agencies should hold an inservice on the managed care specialists’ role and how staff could most effectively communicate with them.

The managed care specialists also could be involved in giving staff regular education and updates. It also might be helpful if the managed care specialist distributed a list of documentation tips for staff. Trask offers this example:

Fee Agreement

View ALL insurance cards. Document all ID numbers for all insurance on forms.

• Document agency charges.

• Document patient portion/co-pay amount; this information can be found on the referral.


• All managed care Medicaid or Medicare patients require full assessment.

• Project the frequency and duration for the full nine weeks. Your discharge plan may be shorter.

• Document short-term goals with time frames.

Clinical Progress Note

• Each week document:

    — homebound status

    — wound measurements

    — patient/caregiver ability to learn, willingness, or availability to provide care

• Document coordination of care, including the managed care specialist.

Discharge Summary

• Reason for discharge cannot be "no further insurance authorization."

Interim Physician Orders

• Authorization does not equal a physician’s order!

• Obtain a physician order for all changes in the plan of care:

    — frequency

    — added discipline

    — treatments

    — medication changes.

"It takes teaching and mentoring, but once the nurses are exposed to the process a couple of times, teaching won’t be as necessary," Trask says.