Managed Care pt's in SNF's

  1. Two issues--I'm the ADNS of a 142 bed SNF. We have Med A patients, Medicaid Patients, private pay, and many different Managed Care Contracts.
    1. Who is responsible in most SNF's for Managed Care?? Getting the auth. from the company and sending in the updates for recerts? I find this takes me three times as long as any of my other jobs and I have PLENTY of those.
    2. What is the recourse for horrible attitudes from managed case managers? I had one scream at me today because I said I "assumed" the patient would need PT/OT at my SNF because he had been brought into the hospital status post accidental OD, had been on a vent and was very deconditioned. She told me that as long as he could wash his hands and face and walk a few feet, I should not assume he would be approved for a rehab stay at a SNF. ????????????? I didn't want to say anything to this woman because my patient's length of stay is dependant in part on her opinion....any ideas?
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    About CapeCodMermaid, RN

    Joined: Nov '02; Posts: 6,023; Likes: 9,119

    3 Comments

  3. by   alintanurse
    Quote from CapeCodMermaid
    Two issues--I'm the ADNS of a 142 bed SNF. We have Med A patients, Medicaid Patients, private pay, and many different Managed Care Contracts.
    1. Who is responsible in most SNF's for Managed Care?? Getting the auth. from the company and sending in the updates for recerts? I find this takes me three times as long as any of my other jobs and I have PLENTY of those.
    2. What is the recourse for horrible attitudes from managed case managers? I had one scream at me today because I said I "assumed" the patient would need PT/OT at my SNF because he had been brought into the hospital status post accidental OD, had been on a vent and was very deconditioned. She told me that as long as he could wash his hands and face and walk a few feet, I should not assume he would be approved for a rehab stay at a SNF. ????????????? I didn't want to say anything to this woman because my patient's length of stay is dependant in part on her opinion....any ideas?
    I worked at a LTC as case manager/dc planner and it was too difficult to manage so many patients,my caseload was approx 30 pts. Prior to me, the DON and ADON with the assist of 1-2 MDS coordinators were providing the managed care reps with the info needed for weekly auth. It's too much work for one person--I couldn't do it for long. In answer to your second question-I met at least twice a week with the PT/OT dept. for updates on pts. PT/OT/ST needs, and they also attended the weekly case mgmt for auth meetings to make their recommendations.They were responsible for obtaining auth for PT/OT/ST needs. The HMO case manager never yelled at them. I hope this is helpful.
    Last edit by alintanurse on Jan 28, '05
  4. by   donmomofnine
    Our admissions nurse takes care of all that stuff!
  5. by   alintanurse
    CapeCodMermaid, At the LTC facility where I worked,I was responsible in obtaining auth for managed care pts.on a weekly basis. The weekly auth meetings were attended by the administrator,DON,PT/OT,social services and myself. I was responsible to provide managed care rep with info needed to continue pts. stay. The managed care reps did not yell at anyone--maybe because they were outnumbered. My suggestion would be not to meet with the reps by yourself,include ancillary depts and the administrator. You may need to consider opening up a new position and have that nurse handle auth.You are wise not to say anything to the rep because they play a part in the referrals you get for admissions to your facility.
    Last edit by alintanurse on Jan 30, '05

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