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Case Managers
The front line defense for profitability in the acute sector
The issue of health care delivery and payment is the topic of choice in the health care industry. Acute stays are becoming more difficult to manage and the need to manage earlier is becoming evident in the industry. Major issues for all acute facilities are those catastrophically ill patients that are on a DRG reimbursement protocol. The following is a dialogue of the issues that face the hospital structure and what can be done by the case managers to make certain that they do not fall victim to the financial losses resulting from "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 whose charges are 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. This issue is the greatest cause of excessive accounts receivable as well as ever mounting debt to the hospital administration.
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 (Medicare) will pay to a hospital as an "administrative day rate". This rate is not meant to match the charges (their real cost of that particular patient). Quite to the contrary. It is a token rate to offset a minute portion of the expense, while you the Case Manager look for appropriate long-term care settings that this patient can be moved to. It is critical that the plan for discharge of a patient from an acute facility start the day that patient is admitted. Again, as mentioned above, the Case Manager can play a very significant role in minimizing the number and cost of outliers to your hospital.
How can you as a case manager help the acute hospital?
- By providing a viable option and mechanism for payment of the skilled without cost to that resistive family.
- By explaining to the family that there are federal funds available to pay for the care of their loved one at the skilled level.
- By assuring the family that they need not lose all the ill person has worked for so many years.
Companies such as ours, NHS, can work alongside the hospital staff and the case manager to make certain that the necessary move from acute to sub acute will be painless and without financial ruin to the resistant and often non-compliant family. With services from a company such as NHS the family will protect the house, the savings and the estate, so when the patient does recover, at least their finances will still be intact. By offering this funding solution as an 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. Skilled facilities won't turn down a patient if they know at the time of intake the family has made arrangements for long term care that will be funded through Medi-Caid or Medi-Cal.
We have produced a NEW Videotape that is now available to you, your staff and your clients FREE of charge regarding Long Term Care Medi-Cal. The video is also available in Spanish.
We also provide FREE LECTURES to various professional and social organizations.
Call us for assistance - (800) 773-6467.
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