Managed Care Control

One of the golden opportunities for becoming the rehab facility of choice in your community is to be an extraordinary partner and a preferred provider with managed care organizations. Superior communication is the remarkable simple key to success, yet so many facilities do not implement systems and organizational strategies to keep the external case manager informed and integrated into the overall management of the patient. The external case manager can become our biggest ally, and as trust is built and outcomes are achieved, the result is nothing but extraordinary for our patients.

Some of the key factors that have proved to aid in achieving that goal include providing documentation and updates to the managed care organization’s case manager, either directly or indirectly through a case manager at the facility.

The top five ways the therapy team can help may be summarized through the following tips and ideas:

1) Provide accurate, concise, thorough and comprehensive information. It is critical that the information shared with the managed care organization’s case manager be a reflection of the patient’s current status. It is also a good idea to discuss the overall treatment plan and discharge goals at this time. This review must be supported by documentation and should reflect detailed information relevant to the current status and progression toward the discharge goals for the patient. It should also reflect our commitment to the patient achieving the outcome necessary to produce a successful and safe discharge. Assist by stressing to the team how important the process of identifying a discharge goal is and how it can eventually become warranted justification for extensions in Length of Stay (LOS). If progress has not been made, be prepared to assess if the current stated goals are still appropriate or if a change in treatment plan is required. The managed care case manager will not continue to authorize days or extend a LOS if given the same information week after week and if progress is not evident.

2) Review all documentation/updates before sharing the information with the managed care organization. It is important to review this information before it is presented so you can justify what may be your eventual request for additional days or a higher level of care. For example, if the overall status of the patient has declined since last week, be prepared with an explanation as to why and what occurred prior to anyone calling the managed care organization’s case manager. These are just some of the questions to be considered and answered prior to submitting documentation/updates:

  • Has there been a change in the patient’s overall health status that has impacted the treatment plan for therapy? If yes, make sure it is documented appropriately.
  • Is the patient refusing therapy? If yes, why and how many times has therapy been refused and how has the patient’s progress been affected?
  • If the patient does not seem to be progressing at all, does the documentation/update reflect why? Are we targeting realistic, achievable goals for the patient?
  • Is the current discharge plan achievable? Do we need to revise the plan? Make sure the revisions are communicated with detail as to why. In most situations, sending therapy notes is not sufficient in itself and will probably be sent back with a request for more information. A clear understanding of the content of the entire documentation/update (nursing and therapy) can prove to be a timesaver. Read it before you send it!

3) Ensure timely reporting. Make sure documentation/updates are submitted on the date they are requested. Most managed care organizations will stipulate a deadline for review, but if possible, it is good practice to tell the managed care case manager when the facility team meetings/conferences are held and suggest that updates are scheduled on those days, thereby providing the most current and accurate information. It is good practice to make sure a definitive date for the next review is agreed upon.

4) Anticipate the managed care case manager’s questions/concerns. It is always good practice to try to anticipate what the managed care organization’s case manager will need in order to authorize additional days or bump a patient to a higher level of care. The obvious question is, “Did the patient make appropriate progress?” If the patient has not made appropriate progress, we must be prepared to answer why and give them clinical justification as to why the patient’s inpatient stay should be extended (e.g., strengthening, safety issues, cognition). In any event, the managed care case manager will almost always want to discuss the current treatment and discharge plan’s viability — for example, when the discharge plan is for the patient to return home, but treatment progression has clearly defined the patient unable to gain enough function to manage at home. At this point, the managed care case manager will expect that we identify a new discharge plan. The Ensign Team should recommend to the managed care organization’s case manager the new most appropriate discharge plan. Also, if we are asking for additional services to be covered, we will need to be prepared to explain why that service is needed and how it will impact the agreed-upon discharge goal. For example, if you are requesting more units, be prepared to defend the rationale as to what value the extra units of therapy bring to the outcomes of the patient’s stay.

5) Be able to discuss progress toward desired outcomes/discharge plan and estimated LOS. When giving an update, focus the discussion on the desired result of care and the resultant discharge plan. Concurrent reviews of the patient’s status during the stay should evaluate the appropriateness of the current treatment plan and its success at achieving the final discharge result. For example, let’s say you have an 85-year old man who just suffered a massive stroke. His deficits are significant. Upon admission, he requires maximum assistance with all ADLs and transfers and is only able to take a few steps on the parallel bars. He suffers from significant swallowing problems and currently has a feeding tube. He is also incontinent of both bowel and bladder. His wife is 81 and very small in stature. The team agrees that an appropriate discharge plan must include, but not be limited to, her husband being able to toilet independently, transfer on his own and manage three steps to enter the home in order for the wife to be able to care for him alone. Every time this patient’s progress is reviewed, the focus should be on progression toward the discharge goals. If at some point it is clear that the patient is making minimal progress, the team must re-evaluate and design a more appropriate discharge goal and plan. For instance, it becomes clear that the patient will not reach his goals and be able to go home; you should be able to document that a different option has been identified. Finally, always be prepared to give the managed care organization’s case manager an estimate of how much longer the patient needs to achieve the agreed-upon goals/desired outcomes.

By Dawn Webster, Managed Care Resource

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