snotpikkr

I can't answer that question, but there is a customer service number for every patient's own insurance that they have the right to call. We have had HMO patients refuse to be discharged and go that route, but the Patient Right to Appeal Discharge pertains to Medicare and Sr advantage patients (signed over benefits to a senior HMO) in Ca.

This has been in effect in CA for over a year (feels like it if not..) where the patients have the right to appeal their discharge. Upon admission, all Medicare and senior managed care (Mcare elig) patients are given the Important Message from Medicare. They are provided with very clear instructions what to do if they think they are being discharged from the hospital too soon. They also must be provided this letter of acknowledgement 48 hours prior to discharge so they can have time to "think". If it is not given 48 hrs prior to discharge, it has to be presented 4 hours before discharge and they have that time frame to decide if they want to go home. If they appeal their discharge and call HSAG or Lumetra etc, their discharge is stopped. The whole chart has to be sent to them for review. A physician will make the decision whether the patient is ready for discharge. The patient has 3 days while waiting, and if the MD reviewer agrees with the hospital, the patient is discharged on the 4th day by noon. We give the letter to the patients on M-W-F to make sure we comply with the time frame as specified. We try and downplay having it signed so the patients don't panic at the thought of being discharged too soon. Of course if someone is critical, it isn't signed every other day! Hope this helps.

I have trained many nurses from the floors. In my opinion, as long as you have a good clinical background for the area you will case manage or coordinate, you'll be ok. Interqual will be another thing your trainer will show you how to use. Ours is built into our computer system. If not, you will be provided a book as a reference. Good luck!

My mistake, Dria. The first post I read did not state she worked for an insurane company so I offered my opinion, which is what this is for.

We as acute hospital case managers don't routinely call the patients after discharge- we rely on the health plans to do that- it is their responsibility to follow up and case manage the patients. We encourage and sometimes make the follow up appointments for the patients even thought they may not follow through with keeping it. The under/unfunded or homeless patients do not want your assistance. They want to come in, get the acute problem fixed, and be on their merry way until they aren't feeling well again. We do offer to fill a few days of prescriptions for them if they really have no funding. Not ideal, but reality.

IQ is not very patient friendly, that's for sure, and that's what we use at our hospital, however when a patient doesn't meet the criteria, our physician advisor overrides the criteria. Everyone including Medicare knows that the criteria is not always appropriate. It gives McKesson a good laugh every day, though. They also run Comedy Central! It's an expensive program we're all subjected to.

Congratulations! What I tell my staff- No one dies because of the paperwork you do. Your job is never done in a day. When it's time to go home, you need to go home. Being a Case Manager is stressful enough without adding unnecessary stress to yourself. I've been in hospital based CM for over 20 years and came as a new nurse with a pen. Now using computers is a big help. Know your clinical area you'll be assigned to. It helps. Enjoy and keep us posted.

Welcome to the world of frustration and rebound patients. You have to know that what you did on the last discharge will have no impact on the patient for his/her readmission. When a patient is noncompliant, there's little you can do to help or teach them. If the patient is connected to an insurance plan (frequently they aren't and the hosp is their only medical care) you can call and have them case managed by the insurance company. The MD office has an obligation to return a call to you. You are doing HIM a favor by assisting his patient in the safest discharge possible. Be insistent, talk to the head of the department (medical, surgical, etc) and voice your frustrations. One of my case managers called the office and said she was the Dr's wife just to get him to come to the phone!