Ask MyCaseManager Monday- Nursing Home-How long will my insurance pay?

Dear MyCaseManager,

My father was just admitted into a nursing home  for physical therapy.  I am so glad that he is finally in a facility.  He has been living alone and I am really worried about him.  How long can he stay at the nursing home and how long will his insurance pay for this?

This is a common question. First, we will need to understand what is paid for by Medicare/health insurance.  Medicare and most private insurance pays for “skilled care” at a nursing home, or skilled nursing facility as they are referred to in the medical community.  Medicare’s (and other medical insurance) definition includes care needs that require a licensed nurse or rehab professional at least daily.  Skilled professionals include, RNs, LVNs, Physical Therapists, Occupational Therapists and Speech Therapists.  Functions to assist with activity of daily living like feeding, bathing, dressing, even administration of oral medications, are not considered skilled need.  They are referred to as custodial care and are not paid for by medicare or any other medical insurance, with the exception of medicaid, unless there is also a skilled need.   Some long term care insurance policies cover custodial care in a skilled nursing facility.  If you have this type of policy you should check with your insurer about this.

From your information, it sounds like because your dad was specifically admitted for Physical Therapy, he is probably under the skilled benefit.  The facility therapists will continue to work with your dad until he meets his treatment goals or he plateaus in his progress.  Most insurance plans have a 100 day per year benefit for Skilled Nursing.  However, it is a rarity that a patient will need 100 days of service at one time to meet the treatment goal or plateau criteria.  Usually this is done within a matter of days to weeks.  The facility should meet with the patient and family soon after admission to discuss a discharge plan.  In your case, if you and your father are interested in him staying at the skilled nursing facility after the skilled benefit runs out, you will need to discuss other financial arrangements with the facility, such as a long term care insurance policy, medicaid or a private pay agreement.  It is important to address these issues early after admission so that you are not in a panic when your father is no longer eligible for his skilled benefit.  If you and he decide that a continued stay is not feasible, you should discuss other options with the discharge planner/social worker at the facility.  Other options for care may include a home caregiver, Adult Daycare Programs, local community Senior Center Services, etc.

Please also check out this great publication by the Oregon Health Care Association that gives more detailed information about the Skilled Nursing Facility medicare benefit.  Again, most private insurances also go by the same guidelines as established by medicare.  http://www.ohca.com/docs/medicare_coverage.pdf

Knowledge is Power!

Live Debate on Health Care Reform- House of Representatives

This is really important.  Whatever opinions you hold, stay informed.

http://www.msnbc.msn.com/id/21134540/vp/35966604#35966604

Ask MyCaseManager Monday- Does my doctor have a Case Manager?

Dear MyCaseManager,

Do all doctor’s offices offer Case Management services?  Do you think I would potentially have access to someone like you at my doctor’s office?

The doctor’s office based Case Manager model is not one that I have seen in many health systems.  However, because of it’s success, I think we will be seeing more of it.   I certainly recommend that you ask your doctor about it if you think you would benefit from Case Management services.  What you will more commonly find are Case Managers that coordinate care for patients with high cost medical needs, like spinal cord injury, premature infants, cancer diagnoses, etc.  A Case Manager like this would assist with referrals and authorizations and coordinate care between specialists.  Many insurance companies also have Case Managers.  You can contact your health insurance company to inquire about this.  If you have a work related injury or illness, you most certainly will be assigned a Worker’s Compensation Case Manager, whose job it is to make sure you have appropriate care and support so you can recover from your injury or illness.

The doctors I work with really value having a Case Manager in their office to assist them with the management of their patients, and I know that our patients appreciate having a source of information and an advocate.  I hope more hospital systems and physicians adopt this model of care.

Ask MyCaseManager Monday-Prescription drug HELP!

Dear MyCaseManager,

I recently lost my job and of course with it, my health insurance.  I can’t afford COBRA at even the reduced costs that are available now.  I have a few medical conditions that I take medications regularly for.  One of my medications is really expensive and if I don’t get some type of help, I will not be able to continue to take that medication.  Is there anything out there to help me?

Actually, there are a few avenues for you to check out.  The most expedient is for you to call your local Wal-Mart and find out how much the medication is there.  Wal-Mart is selling many medications for much less than you will find at various other pharmacies through their $4 Prescription Program http://tiny.cc/tm9Tt .  If the medication is covered under this program, the cost is $4 for a 30 day supply.  If your doctor will write you a prescription for 90 days at a time, the cost is reduced to $10 for 90 days.  This is less than many insurance copays.  Even if your medication isn’t covered with Wal-Mart’s $4 program, you may find that you can still save money over some other pharmacies.  They have bulk purchasing power, as they do with their other merchandise, which can often mean a savings for you.

Additionally, there are Patient Assistance Programs that are run through the individual drug companies.  There is some paperwork involved, but if you qualify, the medications are free.  You can find out more about these programs through NeedyMeds.org  http://tiny.cc/o6tKL .  Qualifications are income based.

For seniors, disabled people or low income women with children, you can also check to see if you qualify for your state’s medicaid program.

Thanks for your question!

Online Senior Resources

With more and more people becoming skilled at navigating the internet, we are now finding an increasing level of senior resources online.  This is helpful because of the convenience factor and the fact that it can be a huge timesaver.  It doesn’t take the place of in-person research to finalize any decisions, but it is very valuable when just determining “what’s out there”.

A resource that I have used in magazine form for years is the New Lifestyles directory. Their list of resources are updated periodically and new magazines are available for specific geographical areas quarterly. New Lifestyles publishes “45 guides for metropolitan areas in the U.S. and we recently expanded into Canada, partnering with TheCareGuide.com, a Canadian company. Five guides are available for Canada.” http://tiny.cc/JMkYh The guide is free to consumers and is financially supported by companies that advertise in the magazine.

The online version is especially handy for those of you that are frequent users of the internet to gather information.  I highly recommend this resource.

You can find them at http://www.newlifestyles.com/

Another website that I recently have discovered is http://www.SNFtour.com .  On this site you will find a number of Florida Skilled Nursing Facilities (SNF) listed by county.  Most of them have online “tours” which are marketing videos about their facilities.  Of course, you have to realize that these videos are made to show only the best side of any facility, it still can be beneficial to get an overall sense of what is available in the area.  It would be interesting to see more communities use this type of marketing.  Again, when choosing a SNF, it is important to actually visit the facility yourself and talk to the staff and other residents.  Please refer to the article I only stay in 4-5 Star Nursing Homes? for more information about researching SNFs.

I encourage you to check out these resources.  If you have other favorites, please comment here or send me a message at MyCaseManager@hotmail.com .  I’m always on the look-out for new sources!

Knowledge is Power!

Free Professional Housecleaning for Cancer Patients

Check out this fabulous resource.

Cleaning For a Reason

It’s What We Do!  Fighting cancer is difficult enough, but living with it is even tougher-and that’s where the Cleaning for a Reason Foundation steps in.  This nonprofit offers free professional housecleaning and maid services to improve the lives of women undergoing treatment for cancer- Any type of cancer.

http://www.cleaningforareason.com/

Ask MyCaseManager Mondays!!!

Ask MyCaseManager Mondays!!!

Hi Everyone!

I am so grateful to all of you for your support of this blog!  It is really satisfying to be able to provide help to the internet community in some small way.

I would like to announce that MyCaseManager will be taking questions from you and answering them in this blog each Monday.  If you have a question related to any of the blogs I have posted previously or any other Case Management/Nursing/Health Care questions, please send them to MyCaseManager@hotmail.com . I will be answering at least one per week.  If you have the question, I am certain that others out there will benefit from the information too, and that is what this blog is all about, empowering patients/consumers with information so they can take a more active role in their health care!  Knowledge is Power!

Again, the email address for all questions is MyCaseManager@hotmail.com

I look forward to hearing from you!

Health Insurance 101(Part II)-Authorizations/Denials/Appeals

If you are in a health plan that requires authorization to for tests, procedures and to see specialists, this is one area that can often seem like a black hole of luck.  “I hope I’m lucky and I get authorization”…..or “I hope I’m lucky and I get my procedure authorized this YEAR!”  Actually, health plan authorization processes are regulated and must follow certain guidelines.  That is not to say all of them do, but if they consistently are out of compliance with their process, they meet certain consequences from their oversight organization National Committee for Quality Assurance (NCQA) http://tiny.cc/FFt6X;  the most severe of those is losing accreditation.  Certain “turn-around times” must be met, which is the time from when a doctor makes a referral to when the insurance company reviews it and then processes the authorization or denial.   NCQA requires standard of care medical information to be used when reviewing the medical necessity of a referral, test or procedure.  They require medical necessity denials to be reviewed by a physician.  They also require certain language to be used in denial letters that give patients their rights of appeal of the denial.

What this means to you, is that the common myth that “bean counters” are sitting in an office somewhere arbitrarily approving or denying your medical requests, is just that, a myth.  There are RNs and MDs that review for medical necessity based upon community standard of care and like previously stated, all denials must be processed by a physician.  This doesn’t mean that everything always goes like it should.  Mistakes can be made, which is why it is important for you to somewhat understand the process, the review methods and your rights.

You should not be waiting weeks for a referral to be processed through your insurance.  The process should be complete within three days, if all medical information to justify medical necessity is provided by your doctor to your insurance provider, or fifteen days if more information was needed.  Let’s say a patient is being referred to an endocrinologist because their diabetes is hard to control.  In most cases, they primary care physician (PCP) must provide medical information to the insurance company showing that the referral is medically necessary.  This might include PCP  office visit notes, lab results, list of medications, etc.  Sometimes hold ups occur because PCPs do not provide this information.  Additionally, sometimes denials occur because PCPs do not provide the adequate medical information.  If you have been denied a service, and you think clearly there is medical necessity there, ask your PCP what information was given to the  insurance company when they made their determination.  You may have to speak with the doctor’s medical assistant or referral’s coordinator, to ge this information too.

This takes us to denials and appeals.  Denials may be issued for a number of reasons:

1.  The requested provider may be out of the insurance plan’s network of contracted providers.

2.  The requested service may not be a covered benefit under your health plan.

3.  The insurance company’s  Medical Management Team may have determined that based upon the information provided by your PCP, the requested service is not medically necessary.

With the high cost of medical services currently, an insurance company must negotiate contracts with the providers to keep prices reasonable.  Most insurance companies pay an approximate 33% of billed charges for procedures, tests, and doctor services.  That translates into if you didn’t have insurance and had to pay cash for an MRI, lets say, you would pay $3,000 for that test, whereas your insurance company would pay approximately $1,000 for the same test.  So, it is clear to see why insurance companies do not allow their members to seek services from non-contracted providers.

Each health insurance company usually has a number of different plans with different levels of coverage.  When you sign up for a plan, remember to not only read the booklet of covered benefits they send to you, but keep it in a safe place for future reference.  Often interpreting covered benefits can be a bit tricky.  One example is that many plans have exclusions for “cosmetic surgery”.  However, if it is related to a medical diagnosis, some may cover that cosmetic surgery, such as, work on a cleft lip or palate, breast reconstruction after a mastectomy, etc.

Medical necessity can sometimes be the area of authorization/denial that can cause the most controversy and many times requires the most information received by the insurance company to make an informed decision.  Like previously stated, there are standard of care guidelines available to the insurance company nurses and doctors that assist them in making their decisions.  You or your PCP however, may disagree with the decision.  When you disagree and want the insurance company to reconsider their decision, that is called an appeal.  There are different processes for filing a physician appeal vs a patient appeal.  If the PCP does want to appeal the decision, I often advise the patient to appeal as well.

NCQA requires HMO’s to provide specific appeal information on their denial letters to patients.  There should be a phone number as well as an address.  There are also two types of appeals, an “expedited” appeal and a routine appeal.  An expedited appeal is when there is imminent danger of loss of life or serious injury to the patient.  These types of appeals must be handled within 72 hours, or less if the situation dictates.  Routine appeals must be resolved within 30 calendar days.  I recommend that for routine appeals, patients write a letter.  In this letter, carefully address your issue and reason for disagreement of the denial.  If you have medical information/medical records to add, send them with the letter as well.  Many patients feel that there is no use to going to the bother of writing an appeal.  My experience leads me to disagree.  I have seen a number of denials that are actually overturned on appeal.  Not the ridiculous ones, like a request to put in a swimming pool in the back yard for exercise needs, or the requests for a facelift to assist with mental health, but most serious appeals are overturned.  If you aren’t a good letter writer, maybe solicit the assistance of a family member who is.  Don’t threaten or be abusive in the letter.  State your case factually and emphatically.

If you are interested in the NCQA guidelines that are used to accredit insurance companies, you can find them at this link.  http://tiny.cc/NeO9e For information specific to this article, scroll down to the category named, Utilization Management (UM).

In this article I have discussed the process of authorizations/denials/appeals for most HMO insurance plans.  These  exclude Medi-caid and Medicare, who have their own processes.  I will discuss these in a future article.

Knowledge is Power!!!

Losing loved ones

Losing loved ones is never easy.  My father passed very early Friday morning, 2/12.  He will always be in my heart and will remain my hero.  Hospice was wonderful in caring for my father and my family.  I will be writing a post about Hospice soon.  Thank you for your patience while I am going through this difficult time.

http://www.camarillomortuary.com/sitemaker/sites/rosepe0/obit.cgi?user=172561Foster

my dad

My dad is very sick and in his last days.  I am flying back and forth from home to his house to help care for him and work.  I wont be posting as regularly, for awhile.  Thanks for your patience and prayers.