Hospitals Avoiding the Loss of Outliers
Jul
23
Written by:
7/23/2010 7:11 AM
AVOIDING THE LOSS OF OUTLIERS
- What is an outlier? This term refers to a Medicare recipient who has remained in an acute care facility beyond the allotted days anticipated for a particular illness and who has charges in excess of the total DRG reimbursement. This is usually someone who is catastrophically ill, with many needs, such as ventilator respiratory support, dialysis, feeding issues, etc.
- Who pays for outlier services to an acute care hospital? These services are factored in to a cost report submitted to Medicare on an annual basis. They determine what kind of a per diem rate they will pay to a hospital as an “administrative day rate”. This rate is not meant to match the charges. Quite to the contrary. It is a token rate to offset a minute portion of the expense, while you look for appropriate long-term care settings.
- What kind of facility would that be? Most likely a sub-acute unit.
- Who will pay them? The care in a sub-acute unit is covered by Medicare only if skilled nursing benefits are available. In other words, only if the patient has not already exhausted those benefits. Bear in mind, the Medicare skilled benefit only pays in full for the first 20 days. On day 21 the patient becomes responsible for 20% of charges.
- How much is that? Depending on the care required, the monthly charges can be over $40,000.00 per month.
- Why would any family agree to move a patient out of the hospital if they stand to pay that kind of money? Exactly! Families become very resistive to that move. The hospital is telling them they have to begin to make arrangements to go to the next level of care, and the payor source is telling them the bill will be astronomical in a matter of days.And the sub-acute unit tells them they need a $20,000.00 deposit. Why, indeed, would any one cooperate with such a plan?
- How can NHS help the acute hospital? By providing a viable option to that resistive family. By explaining to the family that they need not loose all the ill person worked for so many years. They can protect the house, the savings and the estate, so when they recover, at least their finances are intact, if not their body. By offering this option, an acute care hospital can begin early to identify the person at risk of becoming an Outlier, and act early to intervene with the family so appropriate care can be provided at the appropriate level, and all the providers will be funded. Sub-acute facilities wont turn down a patient if they know at the time of intake the family has made arrangements for long term care Medi-cal.
- Who, at the acute care hospital, would identify these potential Outliers? The CFO, the Director of Utilization /Case Management, The Admissions Supervisor/ the Financial Consultant, and certainly the Doctor taking care of the patient. As complications arise, everyone should be aware of the expected discharge requirements and plan ahead by setting up a family meeting to review all the aspects of ongoing care. Of course, the financial aspect is a huge part of the decision process. Finances should never be a reason to terminate care. And, lack of understanding options should never be reason to delay discharge to the next level of care.
- Who pays NHS for their service? Normally, the family of the patient pays the fees. However, an acute care hospital loosing thousands of dollars daily, can option to pay the fees for the client, and cut their losses, so to speak.
- How fast can NHS have long term Medi-cal for someone? Once all the necessary information is provided, NHS can have the case in a pending status within the same month we get the information. NHS guarantees their work.
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