Hospital inpatient /ED - transport question based on insurance

[RNintheBay]

I just started working for an MCO type hospital , my previous experience was following pts admitted to other hosp/facilities and back to home. I'm new to dealing with insurance or lack thereof (i.e. HMO, HMO senior, Medicare, Medicare & MEdi-Cal, Medi-cal only, noninsuranced, etc etc : need for ambulance bls, gurney van, wc van, reg. cab or uber. It gets a bit confusing on what to utilize, some case managers freely use ambulance depending on coverage for pts who seem able to take a cab lol.

[Medic/Nurse, BSN, RN]

What is the question?

[Neats, BSN]

I am getting off subject and on my soap box (apologize in advance) but this information does apply to what you are saying about CM and ambulance:

I work for an Insurance company and understand your confusion however if this service is not medically necessary and the patient or hospital ends up eating the cost as a patient I would be so very angry and appeal until I no longer had any rights and then go to the newspaper and anyone who would listen to me. I have seen more than once a patient who gets the bill for the ambulance ride and they have to pay it...I do not think it is fair and really think the case managers follow the path of least resistance, not for the benefit of the patient.

Here is some helpful tips for nurses who deal with insurance:

The top 4 insurance companies are what we call BUCA it stands for

Blue Cross

United

Cigna

Aetna

Online each of these BUCA's have policies that you can search for; example transportation under Blue Cross policy. It will come up with state Blue Cross policies and most are pretty standard and spells out the criteria that supports this type of service.

There are two examples I can provide you showing not medical necessary and may have a chance of being denied and why

1. Injectafer iron: this iron IV is so much more costly than say Fereheme IV infusions by up to $2000.00-$4000.00 per infusion. In order to get reimbursed the insurance company wants to know why the Injectafer is being used in lieu of a similar IV iron medication that is more cost effective. I will be expecting to see in the submitted documentation patient allergic to something in Fereheme or patient had bad reaction to this medication. I would gladly approve the Inejctafer once it is supported. If not I will approve IV iron but not this medication AND only if your HgB is low. Sometimes we approve higher cost similar medication because of National shortages of lower cost medication too. Lastly in almost every insurance policy there is a caveat that says something addressing cost "most cost effective" is a common term. Fereheme would be most cost effective based on this example without supporting documentation.

2. Skilled Nursing Service in the home: I understand the need to keep patients in the home and patients need assistance. When a provider write order for Skilled Nursing services the home health company comes to the home and does an assessment. It is determined that the patient needs care, reminders to take meds, to have BP weekly, to assist with wound changes because the patient is obese and can not reach their foot without difficulty for their simple wound change-a nurse visit would help every 3 days for wound changes. The reality is this request would meet for up to say 3 visits for education but the patient can hire someone or have a caregiver (who is taught by the Skilled Nurse) change the simple wound that includes irrigation with NS and cover with non-adhesive dressing, to take weekly BP, and reminders for medication-this is custodial care. This does not take a skilled nurse to perform. What does is if the wound has tunneling, a complicated dressing change or wound vac...these things routinely should be performed/monitored by a skilled nurse

In short it is the patient that is burdened with the extra cost for services that are not medical necessary. As a case manager and patient advocate I am aware of this and want the supporting documentation showing the need for it. And lastly the insurance companies do not keep the monies when a service is denied that money goes back to the company the patient works for. Insurance companies only manage the services the company wants their employees to have.

Thank you for letting me vent on my soap box.

[Neats, BSN]

I am getting off subject and on my soap box (apologize in advance) but this information does apply to what you are saying about CM and ambulance:

I work for an Insurance company and understand your confusion however if this service is not medically necessary and the patient or hospital ends up eating the cost as a patient I would be so very angry and appeal until I no longer had any rights and then go to the newspaper and anyone who would listen to me. I have seen more than once a patient who gets the bill for the ambulance ride and they have to pay it...I do not think it is fair and really think the case managers follow the path of least resistance, not for the benefit of the patient.

Here is some helpful tips for nurses who deal with insurance:

The top 4 insurance companies are what we call BUCA it stands for

Blue Cross

United

Cigna

Aetna

Online each of these BUCA's have policies that you can search for; example transportation under Blue Cross policy. It will come up with state Blue Cross policies and most are pretty standard and spells out the criteria that supports this type of service.

There are two examples I can provide you showing not medical necessary and may have a chance of being denied and why

1. Injectafer iron: this iron IV is so much more costly than say Fereheme IV infusions by up to $2000.00-$4000.00 per infusion. In order to get reimbursed the insurance company wants to know why the Injectafer is being used in lieu of a similar IV iron medication that is more cost effective. I will be expecting to see in the submitted documentation patient allergic to something in Fereheme or patient had bad reaction to this medication. I would gladly approve the Inejctafer once it is supported. If not I will approve IV iron but not this medication (injectafer) AND only if your HgB is low. Sometimes we approve higher cost similar medication because of National shortages of lower cost medication too. Lastly in almost every insurance policy there is a caveat that says something addressing cost "most cost effective" is a common term. Fereheme would be most cost effective based on this example without supporting documentation.

2. Skilled Nursing Service in the home: I understand the need to keep patients in the home and patients need assistance. When a provider writes an order for Skilled Nursing services the home health company comes to the home and does an assessment. It is determined that the patient needs care, reminders to take meds, to have BP weekly, to assist with wound changes because the patient is obese and can not reach their foot without difficulty for their simple wound change-a nurse visit would help every 3 days for wound changes. The reality is this request would meet for up to say 3 visits for education but the patient can hire someone or have a caregiver (who is taught by the Skilled Nurse) change the simple wound that includes irrigation with NS and cover with non-adhesive dressing, to take weekly BP, and reminders for medication-this is custodial care. This does not take a skilled nurse to perform. What does is if the wound has tunneling, a complicated dressing change or wound vac...these things routinely should be performed/monitored by a skilled nurse

In short it is the patient that is burdened with the extra cost for services that are not medical necessary. As a case manager and patient advocate I am aware of this and want the supporting documentation showing the need for it. And lastly the insurance companies do not keep the monies when a service is denied that money goes back to the company the patient works for. Insurance companies only manage the services the company wants their employees to have.

Thank you for letting me vent on my soap box.

[RNintheBay]

@Neats, BSN thanks for your feedback. I currently work as an Inpatient &ED case manager - each dept diff rules, guides. We also deal with lots of public insurance such as Partnership, Medi-Cal, and no insurance which gets tricky sometimes since the resources get more difficult.