Working Together To Maximize the Overall Experience for the Managed Care Patient
As we all know, our facilities have experienced substantial growth in their managed care business in the past 10 years. As with all changes, we will continue to experience certain growing pains. These growing pains are a natural part of the process to become a stronger and more effective team managing the care of our patients while ensuring we are being paid in accordance with the care we deliver.
One of the most important relationships often overlooked in a facility is between the Case Management Team and the Therapy Team. Support and communication is critical to manage the care of these patients and to maximize reimbursement from the managed care companies. Whether your facility has a designated Case Manager or not, it is important to recognize and support the functions required by the managed care companies.
WHAT SHOULD THERAPY EXPECT FROM CASE MANAGEMENT?
- Work with the facility Admissions Department and/or Discharge Planning Team at the Hospital to make sure patients are ready for our facility and we are ready for them
- Verify benefits and eligibility of patient
- Obtain an appropriate authorization from the managed care company which will be a “best guess” based on the clinical data used to support the admission
- Negotiation of the appropriate “level of care” and the rate as per the results of the Therapy Evaluation and consultation with the Clinical Team
- Communication to the Therapy Team of which “level of care” has been authorized and corresponding hours of therapy for the defined level
- Notification to the managed care company of any change in condition
- A professional liaison between the facility and the managed care company so the experience for the managed care company is a good one and they will refer again
- COMMUNICATION AND TEAMWORK
WHAT SHOULD CASE MANAGEMENT EXPECT FROM THERAPY?
- Timely evaluation of the managed care patients
- Clear and concise therapy notes to support the plan of care
- “Push back” from therapy if the authorization/level of care/hours of therapy do not correspond to the preferred treatment plan
- Therapy should understand and know the contract terms
- Communication with Case Management when the needs of the patient change
- Knowledge that the ultimate goal of a Medicare patient may be different than the ultimate goal of a managed care patient – moving through the continuum of care rather than rehabilitation to the highest practicable level before discharge
- COMMUNICATION AND TEAMWORK
Effective management of the managed care patient is critical to the long term success of our facilities’ relationship with the managed care company. There is no doubt that managing a managed care patient requires a bit more administrative hoops to jump through than managing a Medicare patient. That said, the reward for doing it right can result in a big win for the facility. Rewards such as the following:
- Increased managed care census
- Increased managed care revenue
- Increased Medicare census – hospitals prefer those facilities that work with both managed care and Medicare
- Increased trust from the managed care companies can result in us defining our plan of care without hassle
COMMUNICATION + TEAMWORK = SUCCESS!!