Insurance Aspects of Case Management

Hey there everybody, and welcome to this presentation on financial and insurance aspects of case management. I'm your host, Dr. Donnelly Snipes. In this presentation, you're going to learn about a variety of payment models, learn about utilization management and level of care guidelines and what they mean in terms of reimbursement and care determination. And finally, we'll talk about some common insurance terms and principles because there's a lot of them foreign. Let's start out with payment models. There are multiple different payment models, but the four main ones are bundled pay for performance, shared savings and fee for service or private pay. The bundled payment model provides one payment for a specified range of services as opposed to paying each provider individually. So when I was working in community mental health, in residential treatment, we would get a bundled payment. We got paid a certain amount per, per bed day for each individual there, and that had to cover their case management, their nursing care, their psychiatric care, their counseling, any other services they needed. Those services were expected to be provided using that money. There was no way to bill for additional services, except for those things that aren't anticipated in residential. So for example, if they fell, fell and had to go to the emergency room, that would be something else. But anything that's expected to be provided within that particular service, like residential substance abuse treatment, was covered under that one day bed rate. The same thing is true for case management and, and people that are in the hospital or there are a lot of different situations where that may happen. A lot of organizations because of capitation and other things using a bundled model, sometimes combined with some of these other models. The pay for performance model or P4Pmeans that people are paid based on an agreed upon evaluation of the provider's performance for a designated population according to acknowledged benchmarks. So if a provider is doing better, they are more efficient with providing services, then they may get a different rate, they may get paid at a different rate than someone who is less efficient. It basically boils down to the same sort of thing. If you're more efficient, then you can see, you know, potentially more clients. And if you're less efficient, then obviously you're not going to be able to see as many people. The shared savings program means providers get paid for each procedure they perform and receive bonuses for reducing total spending. So as a counselor, for example, if I was on a shared savings program, I would get paid for every time I saw a client. However, if I was able to get a client to a maximal level of gains for that level of care, I. E. Get them ready for discharge in 10 sessions versus the expected 15 sessions, then I would get a bonus for being more efficient and effective. And finally, the fee for service is your private pay. And this can happen if a client doesn't have insurance and just pays you out of their pocket, or if their insurance doesn't cover case management services. Sometimes you may contract with doctor's offices, for example, or, you know, clinics of some sort that receive a bundled payment or receive a day rate, and they want to use case management services in order to be more effective and efficient at providing care. They know that using case management will generally reduce the number of times they need to see a patient and reduce the cost per patient. So they may hire you to do that. A lot of case managers work for agencies, so you won't necessarily need to worry about the specifics of how your agency is getting paid, because everything's been written into your organizational policies and procedures. However, if you find that a client needs a service that is not something that is generally provided, then you'll need to go to your organization or to the person's insurance company and find out if they are willing to provide it. And if they aren't willing to cover that service, then you need to look for other ways to get that service covered. It could be private pay. There could be organizations in the community that provide it for free. You just to start looking a little bit in terms of utilization management, people are expected to keep track of the effectiveness of their interventions and their recovery targets for different populations. I'll use the example again of when I worked in residential treatment. Our benchmarks would be to get people at their maximal level of gains for residential in 30 days and discharge them to a low, lower level of care, at which point they would remain clean and sober and out of the hospital for a minimum of six months. So those were behavioral health targets that we were looking at to see how efficient and effective we were. Using that information, we could modify our approach to not only increase patient satisfaction, you know, getting information about what worked for them, what didn't, but we can also use that information to reduce cost and improve outcomes. So if we're getting a bunch of feedback that this group or this service over here that we provided, we had them doing ropes courses, for example, for a while. And that really didn't seem to be improving the effectiveness of treatment or their. The effectiveness of their communication skills. So eventually we dropped that service and, and replaced it with something else. So utilization management is a really good tool to help you individualize, if you will, the treatment program for your area. And the patients in your area. Because what a person needs in Nashville or New York or Miami is probably going to be somewhat different than what they need in a very rural small town. Formal utilization management guidelines, sometimes referred to as level of care guidelines or medical necessity criteria, describe who's eligible for services, the requirements for continued authorization, the providers that can deliver those services, how much of that service is available to the person, and exactly what must be included in that service. So this gives you a really good guideline from the insurance company. Whether it's Medicaid, Medicare, private insurance, long term care insurance, they will all generally have some guidelines that tell you all of this information. Why is this important? Well, if you don't check all of these blocks, then your service may not be reimbursable. Another example from community behavioral health. We used to bill Medicaid a lot of and it was important that as a program director, the people that I had providing those services had the required qualifications to provide those services and that we were targeting people who were eligible for those services. So some services, for example, could be provided by anybody that was working at the agency, any behavioral health tech. Other services had to be provided by a licensed or certified provider. So it's important to know the requirements for reimbursement. It's also important to know the requirements for continued authorization. If you get through the initial authorization of 10 sessions or 20 hours of treatment or 30 days of treatment and the person is still needing services, what are the guidelines in order to get additional hours or services authorized. The other thing that you can look at is how much of that services is available to the person with Medicaid. Again, sometimes it we would bill for services in 15 minute increments and we were able to bill up to, for example, 115 minute increments per calendar year. And it was important to know that. So we knew how much, you know, if with Medicaid we didn't have to get pre authorization, but that would give us an idea of how much of that service we could bill before we had to figure out some other way to bill for services. As a case manager, you may identify a need that the patient has that's not currently being met. Talked about this a little bit already. In that case, you need to be able to read and understand the insurance policy to see if that service would be covered. That goes back to the level of care guidelines we were just talking about. It talks about services that are reimbursed. If it's not covered by the person's insurance. You may need to look to a community resource like the local area agency on Ag Aging, social service programs or condition specific programs like the March of Dimes or the American Heart association, depending on the condition that your patient or patients have. Another shortcut you can take, especially with something like Medicare and Medicaid that can get very onerous in trying to read all of the manuals is to call the provider helpline and there's usually a 1, 800 number on the back of somebody's insurance card that you can call and find out about getting that service approved. One example, you've been working with Sally for a couple of months. Her, her dementia is getting worse and she's forgetting to eat and bathe. You think part of that may be due to her forgetting to take her medication and believe that it would be beneficial for for a CNA to start coming by Sally's house each day to make sure she's eating, bathing and taking her medication as prescribed. Now, theoretically, Sally is still cognitively able to do most other things. She is safe in her environment. She doesn't need 24 hour care. She's just having these memory lapses with some things. I had a patient that I worked with that had schizophrenia who was living in supported housing. However, we did at a certain point need to up his services and include a CNA or a case manager that came by every single day to make sure he was doing these exact things. So these are potential situations where you might need to add services that aren't currently there. But before you start adding them again, you need to make sure you know who the payor is going to be. If you're working for an agency, check with your supervisor to see if it's something you can set up. The agency may be receiving bundled payments and no further authorization is needed. If you're an independent practice, then you would need to consult the patient's insurance plan to see if it would be covered. If so, who can provide the service and whether you need pre authorization. Pre authorization is needed for some services. A lot of times with non emergency situations with private insurance you do need pre authorization for most things, but pre authorization does not guarantee payment. Pre authorization says if you provide these services in accordance with all of our guidelines and if we determine that we agree that it was medically necessary and you did all your paperwork right, then you'll get paid. So you still have to make sure that all the documentation is submitted correctly and that you follow the guidelines to a T. Failing to get pre authorization when you need it pretty much does guarantee that you Won't get paid though. So it's always best to err on the side of calling and finding out if you need pre auth and not needing it, then not getting it and needing it in the end. So let's talk about some of those terms. I already talked about pre authorization a little bit and most people are familiar with that. But let's start by defining it. Your pre authorization is the step you take to call the insurance company before for providing a service, to get permission to provide that service in order to hopefully better assure that you're going to get paid. A lot of insurance companies do that. They have somebody doing the pre authorization to serve as a gatekeeper to make sure that unnecessary services aren't provided. Now, if there is a pre authorization, most times pre authorization will only cover a certain number of procedures or settings or hours of service. Once you've reached that pre authorization limit, you will need to call to get reauthorization. Getting approval from the insurance company is not hard, it just can be time consuming. Another thing that may trigger the need for reauthorization is time. Sometimes people will get an authorization, for example, for 10 sessions of counseling or 20 sessions of case management in a six month period. Well, maybe Sally doesn't need all of those sessions in that six month period, but as soon as that six month period is up, the authorization is up, even if she hasn't used all of her sessions. So then you need to call the insurance company, demonstrate that there is still a continuing need for services and get a reauthorization. An approved provider. Another one that you probably already know, this is someone who's applied to that insurance company like Aetna or Blue Cross and Blue Shield and gotten, quote, credentialed and added to their provider panel. Now, provider panels are not always open. Provider panels are only open when the insurance company determines that they need more providers in that area. Once they have enough providers in that area, they'll close their provider panel and they won't credential anyone else until they need more people, which can be literally years. So it's important to make sure that the providers that you're using, if you're trying to use what we're going to talk about in terms of in network benefits, it's important to make sure that those providers are on the provider panel and they're credentialed with that insurance company. Insurance companies contract with approved providers to provide services at a set rate. So if I contract with Aetna or Blue Cross or Cigna to provide services, they will contact me and they will say, okay, we will pay you x dollars to provide one hour of counseling and we'll provide pay you X dollars to provide the assessment. And I can either accept that rate or I can negotiate a higher rate. Different providers may get paid different amounts by insurance companies for the same service based on whether they've negotiated a better rate. For a variety of reasons, that's really sort of irrelevant unless you are, as a case manager are trying to get credentialed with an insurance company to independently bill coinsurance. And this and co pays often get confused when we're talking about insurance. Coinsurance is the percentage of the bill the insurance company will pay after the deductible has been met or the percentage of the bill that you're going to pay after the deductible has been met. So it's often expressed as a ratio like 60, 40, which means the insurance company will pay 60% and the patient is still responsible for 40% of the bill, or 80, 20. Those are the most common numbers. Now the person has to have met their deductible first before coinsurance even kicks in. The co pay is how much a person has to pay at each visit, even after a deductible is met and even with coinsurance. So that's when you go to your doctor and you hand them your insurance card. And before you even leave the check in window, they're collecting your co pay. There's often a different copay for office visits, prescriptions and hospital visits. A lot of times those numbers are. Those amounts are listed on the back of your insurance card. Now deductibles, those get even more hairy. Deductibles are how much a person has to pay before the insurance company will pay anything at all. Insurance plans with high deductibles like a $10,000 deductible are often far cheaper because it means the person has to pay a whole lot more out of pocket before the insurance company is on the hook for anything at all. Deductibles are also in network and out of network. So an in network deductible is the amount that the person is paid out of pocket for services from an approved provider. Someone who is in network with that insurance company. If they decide to go to someone that is out of network, they have a whole. They have to meet that deduct meet a whole nother deductible for out of network. So if they have a $5,000 in network deductible, they also probably have a $5,000 out of network deductible and what they pay to in network providers does not carry over to out of network. So somebody may have reached their deductible with their in network providers and be able to start paying just their coinsurance and their copay. If they decide to go to an out of network provider, they're going to have to be paying out of pocket again until they meet their deductible. So deductibles we've got in network and out of network. Most people choose to go to in network providers most of the time. It's more financially beneficial to everybody involved if the patient goes to an in network provider. All right, so let's look at some examples. If somebody has a $5,000 per person, $10,000 family deductible for an insurance company for, for an insurance policy. So this is a family policy and the deductible kind of varies. What this means is the in the p, the insurance company will consider the deductible met and the insurance will start to cover the cost of services for one person after their individual charges have exceeded $5,000 in a calendar year or will start to pay for services for anybody in in the family. They will start to pay their co co insurance after the the entire family's out of pocket expenses have exceeded $10,000 in a calendar year. So let me kind of give you examples with names. I always have a difficulty with abstract things. So $5,000 per person, let's say that I go into the hospital and I need to have surgery and my bills go up to $5,000. $7,000, we'll say 7,000. So I pay $5,000 that meets my deductible and then the insurance company kicks in at that point and pays the coinsurance, whatever that is, for the other $2,000. So if I have an 8020 plan, then they will be paying 80% of the remaining $2,000. If my husband or one of my children gets injured, we the insurance company is still not on the hook for anything because we have not met our ten thousand dollar family deductible. If my daughter, heaven forbid, also has a, has a car accident or something and she has a bill that goes up to and exceeds $5,000, then because our entire family's out of pocket, the total family out of pocket has exceeded $10,000, then the insurance company is now responsible for the coinsurance for anybody in the family that's covered on the policy that gets sick or has to go to the hospital for the rest of the calendar year. These policies reset every calendar year. Another example, the same policy has a $5,000 per person, $10,000 family deductible with no co pay. So they don't have to pay a copay when they go to the doctor or when they go to the hospital. That's actually pretty common now. And the coinsurance is 80 20. Remember we talked about this a minute ago. So prior to meeting the deductible, prior to meeting that five thousand or ten thousand dollar limit, the person has to pay a hundred percent of everything. Once they meet their deductible, the insurance company is going to start paying 80% of the bill and the patient is then only responsible for 20% of the bill. So in 8020 policies this still can add up really quickly. My son was in the neonatal intensive care unit for six weeks when he was an infant and the bundled payment that we paid was like almost $20,000 per day for him to have a bed in the neonatal intensive care unit. So and that was 22 years ago. I can't imagine what it's like now. So 20% of his total bill would have been a whole lot of money. Thankfully at that point we had zero coinsurance. Talk a little bit more about out of network provider benefits. A lot of times it is abbreviated, abbreviated as OON and that means out of network. These are professionals who've not been credentialed by the insurance company and are not on the provider panel. Most insurance policies, again I'm going to state it again because it's so important to understand. Most policies have a whole separate set of deductibles and co pays for out of network providers. That means that nothing that you've paid towards your in network deductible counts toward your out of network deductible deductible. If you use an out of network provider, sometimes it happens it's particular person you want to go to or whatever the case is happens to be. Find out if they will submit the billing on the patient's behalf or if the patient has to pay up front and then the insurance company will reimburse the patient directly. One caveat with these is in hospitals, for example, sometimes people get caught unawares because their the hospital is in network, their surgeon is in network, but oops, the anesthesiologist is out of network. It's really important to make sure that everybody on your treatment team is an in network provider. If you're concerned about that, another term to be aware of is the maximum annual benefit. This is the maximum amount that an insurance company will pay for a particular service each year, for example, 12 sessions of outpatient psychotherapy. Sometimes that's all they will pay for. This is a really common issue with dental plans, for example, where dental plans will only pay for a certain number of cavities or root canals in any particular particular calendar year. The maximum lifetime benefit is the maximum amount that an insurance company will pay for any illness like heart disease or cancer that may be ongoing for many years. Make sure when you're getting your insurance or when you're looking at insurance, you read to see if there is a maximum lifetime benefit for conditions that you hypothetically may have. If you have a history of heart disease, you know you want to see what the maximum lifetime benefit is in your family or I'm sorry, in your insurance company if you happen to develop heart disease, if you have a history of it in your family. Many insurance companies offer discounts on services and ancillary benefits like transportation to medical appointments, equipment for home health like shower seats, and even GEM memberships that are not well advertised. So get to know the policies of the providers in your area because there might be a lot of services that are available either for free or at a significant discount because your person has a particular insurance policy. Disability insurance is a different kind of insurance. It's not medical insurance. The Social Security Disability Insurance program pays benefits to the patient and certain family members if the person is qualified, meaning that they worked long enough and paid Social Security taxes on their earnings. So each year you work, you earn a certain number of points in the Social Security system and once you get a certain number of points then you qualify for SSDI benefits. You can go on to the Social Security Disability Insurance website and look at your you can log in and look at your file to see how many points you have and you can also learn more about it at from their website. Now another insurance that sounds similar is the Supplementary Security Income or ssi. So a lot of people talk about SSI and ssdi. SSI pays benefits to people who are disabled who or have limited income and resources because of their disability. To receive ssi, people have to be able to demonstrate that they are that they have a disability. They have to meet certain criteria for qualifying for ssi. In terms of disability benefits, there are two types of permanent disability. There's permanent and temporary disability. Temporary obviously means that the person has a disability but is expected to make a recovery at some point in time. Permanent disability There is not an expectation of recovery. Permanent partial disability benefits may apply if an employee retains a permanent disability because of a work related injury and is able to return to the job in an open market. So they may not be able to return to their last job. You know, whatever happened, they have a disability that prevents them from returning to that particular line of work, but they are still able to work in some capacity. Per permanent partial partial disability benefits pay 66 and 2/3% of the injured employees. Average weekly wage subject to limitations depending on the body part affected and the work injury and the employee's ability to return to his or her prior employment or employment. So if the person starts being able to return to a job on the open market, then the benefits that they were receiving when they weren't able to work may be reduced. Permanent total disability benefits may apply if the person is unable to return to any job in the open market because of a permanent disability due to a work related injury. So these disability insurances only apply to work related injuries. This benefit continues until the person becomes eligible for old age retirement under Social Security law. So when they reach that point, they can start drawing on their Social Security. Then the permanent total disability benefits are cut back or eliminated. And finally, workers compensation. Each state has its own unique set of workers compensation laws that employers must follow. Consult your state department of labor to find out the specific requirements. These regulations help ensure that employers provide coverage for the cost of work related injuries or occupational diseases, regardless of employee negligence. So if you've got somebody working at a grocery store and they're goofing around when they're doing some stalking and they end up slipping and falling and hurting their back, okay, well, the employee was being negligent. However, they were doing their work, they were at work, they were doing the functions of their job. So workers compensation would still probably cover this, provided they were not under the influence of substances. When somebody files a work workers compensation claim, one of the first things they do is they have to go get a drug test. Because being under the influence of substances at work generally is a disqualifying condition. Like Medicaid, Medicare and health insurance, workers compensation will rarely cover custodial care or significant in home care. So if somebody, you know, they're goofing around, they fall, they hurt their back, they are bedbound, you know, they, they actually, they cannot get up, they cannot get out of bed while they're recovering, then they are going to need some level of custodial and or significant in home care to get them their meals, to help them bathe, help them toilet, those sorts of things, unless they receive those services in a facility. So it's important to know what the limits of the policy are and what they will or will not cover. And that may dictate person has to receive services. An employee can only receive benefits if their injury or illness relates to their job, duties or employment and they were clean and sober at the time of the injury. One area or time that people are at high risk for injury, for example, may be if they do home visits, case managers, counselors, whomever, when once they are on duty, once they are at their job, if they are leaving their job to go do a home visit and they get into a car accident, they are in the course of their duties that should be reported to workers compensation and workers compensation again, even if the person was at fault in the accident, as long as they weren't under the influence, workers compensation will likely cover it. In general, work related injuries must be reported within 15 days. Some organizations have much shorter reporting windows and some states have much shorter reporter reporting windows. So it's important to just be aware of those it is illegal for an employer to fire an employee for reporting a work injury and workers comp may pay up to 60%, 66% of the employee's salary while they're recovering. And one other type of insurance that is near and dear to my heart that I wanted to put in there because case managers are used extensively in it is Early Steps. Early Steps is covered under Medicaid Part C. And you'll go to your Department of Children and Families website on your state's, you know, website and look for Early Steps. It's called Early Steps just about everywhere. I think it's called Early Steps in every state. This is covered under Medicaid Part C. So you get hired by the people who have the contract in your state to provide these services. You provide services to families with infants and toddlers age birth to three who have a medical condition likely to result in a developmental delay. And this can include being premature, being in the neonatal intensive care unit, or being born under the influence of substances or children birth to three who are identified as having developmental delays. Now, a doctor, a pediatrician does not have to be the one to make a referral to teachers can anybody can make a referral for an evaluation. The child may have to go to the pediatrician as one of the first steps, but anybody can make a referral to get somebody into the Early Steps program. Services that Early Steps programs provide include assistive technology, audiology, health services, medical service evaluations, Medicaid or the person's health Insurance would cover a lot of the other medical services, nutrition, occupational therapy, physical therapy, psychological services, service coordination, case management, social work, special instruction, speech pathology, translation and interpreter services, transportation to, to and from early steps, appointments and even vision services. So they provide a lot of stuff. And the case manager is so integral into helping coordinate all of those things and making sure to get keep all of the providers paperwork in a single place so everybody on the multidisciplinary team has access to it. When my son was in early steps because he was preemie, we had an occupational therapist, a physical therapist, a recreation therapist, and briefly. And did I already say occupational? We, we had all kinds of therapists, plus the pediatrician that was working with them. So the case manager really helped coordinate all of those different providers and all of them, you know, talked about what was needed and we really had a comprehensive multidisciplinary treatment plan which was such a blessing that to to have. While case managers are often employed by organizations which have already integrated all of this information into their policies and procedures, it's still helpful to know the basics of insurance in order to explain them to patients and their families. Independent case managers, those who are working, you know, in private practice, may need to make sure they're extremely familiar with the different insurance policies to determine how they're going to make their money. Private pay or fee for service is one way, long term care insurance is another, and we'll talk about that in the next video. And even contracting with physicians to assist them in reducing their cost per patient is another way that an independent case manager may be able to build up a private practice.