Watch for patients who switch to HMOs
Check patients' insurance cards at every visit
One of the biggest problems for hospital-based home care providers who serve Medicare HMO contracts is patients who enter Medicare HMOs without telling their home care providers.
Managers must train their field staff to be on the lookout for these patients. If patients enter HMOs
without your knowledge, and you still perform visits for these patients, you are likely to go without
reimbursement for the services provided. Medicare certainly will deny your claims for these patients,
and the patients' new HMOs will likely refuse to pay you, as you
didn't receive authorization for the visits you performed.
Most sources interviewed say they trained their nurses and aides to check Medicare patients' insurance cards at every visit. Some providers augment this by teaching their nurses to ask all patients if they've recently changed to a new insurance provider.
"You have to be careful though, because just seeing their Medicare number alone doesn't identify them as HMO patients," Kelly says.
Christ Hospital Home Health and Hospice in Jersey City, NJ, tackled this problem by photocopying the insurance cards of all of the managed care companies with which the company has contracts and giving each nurse a sort of brochure or template of all these cards. When field staff members check patients' insurance cards at every visit, they can know immediately whether the patient is covered by an HMO that Christ Hospital Home Health and Hospice works with by comparing the patients' cards to their template.
This solution doesn't help when patients haven't received their new insurance cards or are confused about what type of coverage they have, says Susan Havens Lang, RN, MSN, the executive director of Christ Hospital Home Health and Hospice. To increase the chances that visits to such patients will be reimbursed by Medicare HMOs, Lang asks her nurses and aides to take notes about what type of insurance patients appear to have.
"It doesn't always work, but it helps," Lang says.
Being hospital-based can be an advantage as far as this problem is concerned. One patient at St. Mary's Hospital Home Health Care actually switched to a Medicare HMO while still in the hospital, before being admitted to home care. The home care agency managed to avoid submitting claims that would have been denied to Medicare when the hospital case manager alerted the home care agency admissions coordinator that the patient had switched to an HMO.
"That was just lucky, though," says Rosemary Donovan, RN, the company's acting director. "You have to be careful about this." *
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