Giving details to payers enhances relationship

Key areas: Expected progress and LOS

When it comes to approving coverage for rehab patients, all insurers are different, asserts Michele Skripps, RN, case management coordinator for HealthSouth Rehabilitation Hospital in Charleston, SC. They do have one thing in common, however: They want information, and lots of it, about what the patient can expect to accomplish and how long it will take.

HealthSouth’s neurology day treatment program is so popular with payers that it’s not unusual for them to approve treatment for up to a year, even if the patient’s plan has a limited number of outpatient treatments. "As long as you can show that you are making a difference in a patient’s functional level, carriers are willing to pay, especially with brain injury patients," she says.

Providers must help insurance companies realize that without intervention, such as a day treatment program, they could pay for brain injury care for the rest of patients’ lives, she points out. "If we can get the patient to a higher level, they will need fewer interventions and it will save money in the long run."

The hospital has compiled enough statistics through the years to be able to give payers an estimate of how long patients are expected to remain in the program and how many hours of daily therapy they will need. Whenever possible, Skripps negotiates a per-diem rate for day treatment services instead of charging for individual therapy sessions. That way, the external case manager doesn’t decide which therapy discipline does which tasks and whether treatment is on a group or individual basis.

The program’s case manager takes an active role in keeping costs down and works with therapists to find ways to ensure patients receive needed therapy at a lower cost to insurers. For example, when patients get close to reaching their long-term goals in a certain discipline, the staff may cut their therapy hours. "The goal is to get the patients what they need and not abuse the system. The external case managers appreciate that," Skripps explains.

The HealthSouth case manager initially makes sure the payer understands the program will be long-term. They estimate the weeks of therapy it will take to meet long-term goals, and they outline short-term goals.

If policies specify a limited number of outpatient treatments, some payers are willing to work with HealthSouth to fund day treatment if it will keep the patient from going to a long-term care facility. "Most of the time, they’re willing to negotiate, particularly if the family is willing to participate and the patient can be in a home environment," she says.

Talk about progress

The day program has always had an internal case manager who is a registered nurse. The manager also handles the hospital’s outpatient cases. "The payers like to call someone who is clinical who can give them the information they need. If they want specifics or don’t understand something, it’s hard to get a therapist on the phone because they are always treating patients. The case manager is more flexible," Skripps says. "What I hear from the external case managers is that they like being able to talk to someone about patient progress."

The case manager may notice changes — such as behavioral ones — that therapists may not document in their progress notes, then report those changes to the external case manager, she says. For example, a brain injury patient who also was an amputee would become agitated if his mother left the room. The staff initially allowed her to be present during his sessions. Later, they asked her to sit where he couldn’t see her but said she could come in if he became agitated. The patient progressed to the point that his mother could leave him at the hospital. Then, he began coming without her in the hospital van.

"These gains aren’t something that a therapist would be likely to document, but it is something that the case manager could tell the payer to help show that he was making progress," Skripps says.

Because he was continuously making progress, the man’s insurance company, a private carrier, paid for the day treatment for 51 weeks. He was discharged in December and is in a vocational rehabilitation program.