Managed care

Talino · Sep 21, 2009

This is called Medicare Advantage Plans (MAP) which a patient had previously enrolled in to avail of Medicare benefits rather than the traditional Medicare fee-for-service, as you call it, Medicare A.

It is important to know how the MAP contractor pays for skilled services rendered by the SNF. Some have a predetermined rate that your billing dept. must be aware of prior to admitting the patient. Others may require the completion of MDS to determine payment based on RUG scores (these MDSs are not required to be transmitted but kept on file for the contractor's reference).

The MAP can deny coverage at a certain point even if the SNF believes skilled service is still necessary, making the patient financially responsible thereafter. Hence, regular communication with the contractor (usually by a biller) is necessary. Often, these MAP limitations drive beneficiaries to disenroll from the plan and switch to traditional Medicare. When this happens, the MDS Coordinator must be alerted immediately so a required MDS/PPS assm't can be conducted timely when traditional Medicare takes over.

Rascal1 · Sep 21, 2009

Thanks for the reply. I just did a brief and painful four weeks at a large SNF w/ a short term rehab. I had applied for an MDS position there,upon completing the required fire safety,hepatitis..I was sent down to the MDS office,where I met one of the others and had a brief orientation to the managed care process. Wow, was I in shock! Their short term rehab.unit consists of mostly managed care w/ little Medicare! Our job,two of three of us was to copy and fax.chart information every week,respond to phone calls and requests for more documentation from the managed care companies. And we were respondsible for completeing all the MDS's. What causes such a huge proportion of managed care patients ? thanks..

Talino · Sep 21, 2009

What causes such a huge proportion of managed care patients?

Cost primarily plus add'l benefits - Medicare Advantage vs Original Medicare sample only.

susanthomas1954 · Sep 26, 2009

Yes, I feel your pain. You are doing CASE MANAGEMENT!!!!!! Why facilities think that MDS co-ordinators can do managed care case management is a huge mystery to me. Many of these plans do not follow medicare guidelines, and you end up becoming the bad guy who has to go in and tell someone who can barely crawl to the bathroom on all fours that they now qualify for a "lower level of care" because they have junk for insurance.

I realize I am venting, but the point here is that these plans are not paying as well as Medicare, and they are costing the facility big buckets of money when they pay by level instead of RUG, and they have to turn over in 14 to 21 days usually despite the fact that they may have a dense stroke that will require 6 months of daily rehab to be able to possibly feed themselves!

Give me straight Medicare, and I will make your facility a profitable place, but when you bring in the expensive managed care patients, and you pay me to stand around a fax machine all day, your facility will be losing money.I HATE MANAGED CARE!!!!!!!!!!!!!!!!!!

Rascal1 · Sep 26, 2009

Hi Susan! Vent away! I'm doing it!

This placed hired me to be an MDS Coordinator,but come to find out IT IS case management,I've never done it! I was fired in four weeks because they wanted someone to jump in and run with it! Do I have a "leg to stand on?"

susanthomas1954 · Sep 26, 2009

If you've never had any training in case management, it is an abomination that they expected you to do this under the guise of MDS. I'm laying odds it was a Kindred facility?

CapeCodMermaid, RN · Sep 27, 2009

Just a few comments--on what kind of leg are you looking to stand? You got fired because they wanted someone else. Most places can fire you for just about any reason. I have a union in my building but until the probationary period passes, I can fire someone because I don't like their socks! (not that I would, but you get the point.)

I agree....sounds like a Kindred facility. I was the PPS MDS coordinator for a very busy Kindred facility. We averaged between 25 and 28 Med A patients. I was extremely well organized and had no problem managing the load. Then they decided that I should take over as managed care coordinator as well. We had 5 different contracts with at least 10 different forms and ways to communicate updates. I finally told them it was folly to expect one person to do both so the ADON got the managed care stuff. When I was promoted to ADON, I got the job back. You have to be really organized to do the job and make sure you know what day the update is due and what each insurance company expects. Honestly it was one of the most difficult jobs I had.

Rascal1 · Sep 27, 2009

I appreciate your thoughts. They did hire me under the guise of MDS care plan Coordinator and that was indeed

how the job was posted in house. I was excited initially about the new challenges,however without the aid or

assistance of my coworkers in our office I became discouraged. It was very clear they were already inundated

with their own heavy workloads. Even the DON called it an "eat or be eaten environment."

It had been two years that I had been away from nursing and it's simply amazing how quickly the workplace

climate has changed,even withstanding the current economic difficulties.

Rascal1 · Sep 27, 2009

It was 'nt a Kindred home,but a privately owned home of several they own.

susanthomas1954 · Oct 2, 2009

Well, all the facilites in Southern Arizona expect the MDS coordinator to case manage the Med A's which is a snooze, but the case management for managed care is a nightmare. Every payor source has a "special" weekly case management form which has to be filled in for week to week authorization, and you can't usually just say "see attached" and attach your own facility forms which already contains the information they want you to rewrite. They lose the first fax usually, then their fax lines are busy for hours.

BUT! I have learned some tricks for fighting back.

1) As soon as the patient is admitted, I fax everything I can think of, usually at least 40 pages. (These case managers usually work from home, and have to drive into offices to pick up more paper, so this gives them pause before they ask you to fax in stuff they really don't need..let's them know you are serious.)

2) I ask them to "carve out" anything I can think of: expensive meds, special beds, transportation, escorts, anything not specifically defined in the contract.

3) I ask for a "higher level of care" on anyone who remotely qualifies for more therapy than the plan allows, and fax quite a few pages of documentation about why the patient needs it.

If you ever get another job requiring case management another thing you can do is insist on faxing your paperwork in on the same day to all payor sources. This insures that you will have at least two days a week to do just MDS's. I personally can't do MDS's and case management in the same day. Two and a half days a week I do case management, and two and a half days I do MDS's. The problem is case management is so insidious that sometimes you absolutely HAVE to do something right now, no matter when it is. The way I deal with that is let the administrator know how many hours a certain company is demanding of my time, and what it is costing him in terms of my salary. He makes money when I am doing Medicare MDS's. He is breaking even or losing money on my time if I am doing anything else. I get lots of support.

ST

rapkeygurl · Oct 6, 2009

oh your stories of managed care certainly do not look like fun, our company has its own medicare biller but she is not a nurse, tries to tell me how to count PT minutes lol and will ask me are you sure they did not have iv fluids??? I can not imagine doing all that mess on top of the mds's careplans and revisions, I am all for making the best rug score we can but not going to say someone has had 200 minutes when they only had 135!! The problem is that we use out of facility PT and they will not give us but 3 days a week when most of our residents need 5 days a week. Of course it is crap to make these people go out in the cold, take a driver and a nurse aide to transport them off the floor. This is the perils of small facilities