Any Hospital CM/LCSWs here? Got a load of questions about your job.

nuberianne_RN · Jan 17, 2018

What type of program are you enrolled in? I'll attempt to answer a couple of questions.

Each insurance company and regions within the company are different. Some authorize a few days at a time while others approve per visit depending on the clinical information sent in to them. Again everyone is different.

Doctors discharge their patients when they feel like it without our input at my hospital. Assign a length of stay, what does that mean? Yes that's sarcasm...

I don't know what you're keeping track of with Medicare Rights every two days.

That's my two cents

CrazyCoconut · Jan 17, 2018

Thank you. Without getting too detailed, its part of a government agency's assessment of the roles in the hospital. And no, it's not for accreditation or anything. It's more for surveying.

KelRN215, BSN, RN · Jan 22, 2018

I am one of those "liaison people" you speak of. I spend my full work week at the hospital accepting referrals, assessing patients and their families for their appropriateness for home infusion/ability to manage it, doing teaching on home IV antibiotics, TPN or tube feeds and coordinating home care with the people who work in my office- ensuring that the patient will have a nurse when he goes home and that their medications or supplies will be delivered. Case Managers call me when they have a patient who needs to go home with infusion or enteral therapy.

In my opinion, the most difficult insurances to work with are Cigna, United, Aetna and Medicare. The easiest is, by far, Medicaid in my state. It covers almost everything.

Discharging is, by and large, determined by the medical team though sometimes they want to discharge a patient and we have to tell them that the patient is not ready for discharge. I had a patient a couple months ago who the Surgeons decided was ready for discharge on home IV antibiotics. Parents did not speak English and clearly did not understand what they were expected to do as, when I approached them to teach them how to administer IV antibiotics with an interpreter, they both immediately stated that they couldn't do it and refused to learn. The CM and I had to tell the Surgeons that the child could not be discharged.

CrazyCoconut · Jan 22, 2018

I am one of those "liaison people" you speak of. I spend my full work week at the hospital accepting referrals, assessing patients and their families for their appropriateness for home infusion/ability to manage it, doing teaching on home IV antibiotics, TPN or tube feeds and coordinating home care with the people who work in my office- ensuring that the patient will have a nurse when he goes home and that their medications or supplies will be delivered. Case Managers call me when they have a patient who needs to go home with infusion or enteral therapy.
In my opinion, the most difficult insurances to work with are Cigna, United, Aetna and Medicare. The easiest is, by far, Medicaid in my state. It covers almost everything.
Discharging is, by and large, determined by the medical team though sometimes they want to discharge a patient and we have to tell them that the patient is not ready for discharge. I had a patient a couple months ago who the Surgeons decided was ready for discharge on home IV antibiotics. Parents did not speak English and clearly did not understand what they were expected to do as, when I approached them to teach them how to administer IV antibiotics with an interpreter, they both immediately stated that they couldn't do it and refused to learn. The CM and I had to tell the Surgeons that the child could not be discharged.

Thanks for your detailed response. What happened then when you and the CM told the surgeons that? What is the hospital suppose to do when the family refused to learn? They have to pay for IVB Antibiotics?

KelRN215, BSN, RN · Jan 22, 2018

Thanks for your detailed response. What happened then when you and the CM told the surgeons that? What is the hospital suppose to do when the family refused to learn? They have to pay for IVB Antibiotics?

The child stayed inpatient as she did not have caregivers who could manage her care at home. Her insurance paid for the hospital stay. She ended up having many other complications and there were a lot of extenuating circumstances. It was my opinion that she should have transferred to a medical service because her surgical issues had essentially resolved by that point but she still had an extensive infection that needed to be treated but I'm an outside liaison, it's not my place to say that.

GoshoJosh · Jan 26, 2018

Hey! You certainly did observe a lot! I'm an inpatient RN case manager at a hospital. A little over 2 years of experience & recently became certified with both CCM and ACM. I'll try to answer these questions to the best of my ability - it is important to note that it greatly varies state by state.

1. What are the most difficult insurances to work with? Easiest? How difficult is InterQual(?) when accounting insurance criteria? What do you have to do?

In my state, the most difficult insurances are the commercial plans that most people without Medicare (age 65+) have, such as Aetna, Humana, UHC, etc. Commercial plans don't offer very comprehensive home health, SNF, or rehab benefits, which is what many inpatients require upon discharge. Other than that, Human Medicare notoriously denies a lot of services. In the hospital, traditional Medicare (part A) is the easiest to work with.

My hospital does use Interqual criteria to help in determining patient status (inpatient vs observation/outpatient). It isn't difficult, but it does take some getting used to. It divides up reasons that people come into the hospital (ex. pneumonia, CVA, infection of various types, DVT, etc) and then provides clinical guidelines that determine whether their condition justifies inpatient status (was the O2 sat 99.4, WBC > 13,000, etc). To try and give an example, if a 67 year-old presents to the ED with fever, cough and imaging reveals pneumonia, that doesn't alone justify an inpatient stay. Imaging has to show PNA in more than one lobe or there needs to be comorbidities that require monitoring. Otherwise, if the ED doesn't document that they are febrile, that they are tachycardic, etc, then they are not meeting Interqual criteria for inpatient status. In that case, the CM discusses with the physician about downgrading to observation because the insurance will most likely deny. Insurance companies are running their own reviews at the same time to determine if they'll pay, so CM is trying to determine this first to avoid denials. Along the same line, it helps CMs determine if a patient can be upgraded from observation to inpatient if they are meeting the criteria (which results in more money for the hospital because inpatient stays get much higher reimbursement from insurance).

2. How do you determine Length of Stay and when to Discharge? Is it mainly by doctor's orders? What is considered sufficient? Do certain insurances require or allow you to a certain length of stay (Ex: Medicare, Humana, Aetna)?

CM/SW doesn't determine length of stay. But, there are Medicare established length of stays per diagnosis. It's called a GMLOS: Geometric Length of Stay. The CM would have access to each patient's GMLOS, so they can have conversations with physicians about it. "Hey MD, this patient has a GMLOS of 4 days but they've been here 7 days. Are there any other barriers to their discharge that I can help with?" (like setting up home health, etc). But ultimately the physician is solely responsible for deciding when a patient discharges. Insurances will start to call CMs if a patient has a long length of stay to offer discharge planning assistance, but they can't tell a hospital to discharge a patient. They can, however, threaten to stop paying for the stay if they think a patient should be discharge ready.

3. How do you keep track with the Medicare Rights Message thing every 2 days? How do you keep in track of everything in general?

I think you're talking about the IMM: Important Message from Medicare. This is an explanation of rights that a patient has the right to appeal their discharge if they feel like they are being unjustly discharged. Medicare requires that this document is delivered to the patient and signed by them within 48 hours of their discharge. Some CMs give it every 2 days to always be safely in the window, but if you know when your patients are expected to discharge, you technically only have to give it once within 48 hours of their discharge.

4. What is "Obs." and why does it cause CM's to go into a panic/headache when going to "Inpatient?"

Obs is observation status. This typically indicates that a patient is being observed overnight and is expected to discharge the next day. If a patient isn't quite sick enough to be considered inpatient, or the workup hasn't revealed a reason to be inpatient, then observation is assigned to them. For example, if someone comes in for a TIA, this is observation status because patients usually recover fully from a TIA. They are placed in obs and then get a full CVA workup. If the MRI reveals the patient did have an acute CVA or hemorrhage, then they will now qualify to convert to inpatient. If not, they are discharged home with TIA education. The reason CMs freak out when trying to convert is that the hospital stands to gain considerably more money from insurance companies if patients meet inpatient criteria. Not to mention inpatients typically have more costs to be treated appropriately, so the inpatient reimbursement rate is necessary.

5. What does "RW, BSC" mean?

RW: rolling walker

BSC: bedside commode (also called a 3-in-1 commode)

6. Is obtaining the Advance Directive your job or the Social Worker's job? When do you normally have to get it by?

In my hospital, advance directives, MPOAs, etc are handled by the chaplain.

7. How do you know when to place a patient in SNF, LTAC, Home Health, Hospice, or Rehab? What example diagnoses would some patients fall under Hospice, SNF, etc?

Rehab: most intensive form of inpatient therapy. The patient must be able to participate in 3 hours of therapy daily. Also, a qualifying diagnosis is important (if interested, look up "acute rehab qualifying diagnoses". I think there are 13 currently).

LTACH: acute care setting where the focus is not therapy but other medical reasons, like multiple wounds, IV antibiotics, new trachs, etc. These patients require a longer hospitalization but are medically stable because the course of treatment has been established.

Home Health: the patient is safe to return home but just needs some support, whether that is a nurse, therapist, SWer, etc. HH usually visits 3-5 times/week. They do NOT do things like caregiving services (no cooking, cleaning, etc) - caregiving services are typically an out-of-pocket expense that insurance does not cover.

SNF: lower level of care than LTAC. This is if a patient cannot tolerate 3/hours of therapy a day and is therefore not a rehab candidate, or maybe they just need an interim facility before going home. A SNF patient no longer needs to be in the hospital but often needs a little more support before being able to return home and care for themselves.

Hospice: terminal diagnosis from a physician stating that a patient likely has 6 months or less to live. Hospice can be at home, in a SNF, or in a hospital, depending on how sick they are. Comprehensive support, including pain management and palliative care.

8. Who collects "Durable Medical Equipment" or labs? Do you ever place orders for those or do the doctors do it and you get them?

CM/SW orders the DME from DME companies. They do need doctors' orders, but we typically enter those orders ourselves as a 'verbal' or 'telephone' read back and the physician signs the order on the backend. This is because we know the correct verbiage that is needed for insurance companies to cover the DME.

9. Who are those Liaison people from different agencies and hospitals? Why are they at the hospital? When do you call them?

We call them liaisons too. If someone is going to discharge with home health, home infusions, etc, then that agency will send out a liaison to meet with patient face-to-face in the hospital. This helps the company ensure they have the correct contact info and they also discuss what to expect with their services.

10. Can hospitals replace Durable Medical Equipment if more than 5 years old? Or is that the responsibility of the PCP?

Hospitals don't replace DME. The CM or SW orders them from a DME company to be paid for by the insurance. But you are correct, insurance will typically pay for a piece of DME replacement every 5 years.