Case Management

Sneak peek: One simple question about patients’ benefits coverage can eliminate big headaches

Case Management Weekly, November 14, 2012

A physician has recommended an excellent treatment plan for your patient. It looks good on all fronts. But there is one final question a good case manager should ask: Will the patient's insurance pay for it?

Unfortunately, this is a question that isn't asked often enough-which results in payment denials and appeals, and sometimes leaves patients on the hook for thousands of dollars in uncovered medical costs, says Joyce Muller, RN, BS, CCM, CDMS, CMCN, BC, president and CEO of IMEDECS in Lansdale, Pa. If insurance doesn't cover the treatment plan, the patient may also decide not to comply with it, which could trigger an unnecessary readmission.

 A treatment plan that isn't covered by insurance is frustrating for everyone, says Muller. Case managers need to determine whether this is an issue before patients are ­discharged from the hospital. "Unfortunately in today's case management world, in order to be effective, you have to know all these things," says Muller. The best treatment plan in the world won't do much good if the patient can't afford to follow it.

Patients generally have access to details about their benefits coveragemost of this information is now available online, says Muller. If a patient isn't certain where to find coverage information, the patient should try contacting his or her employer's human resources department, she says.

Ask patients to supply coverage information when they are admitted to the hospital so nursing staff can ensure that nothing recommended for the patient's care falls outside the plan. And remember, just because an insurer covers a particular procedure for most patients doesn't mean it will cover the same procedure for your patient. Different employers opt for different levels of coverage, says Muller.

Also, remind patients that just because a policy covered something in the past does not mean that the same coverage exists today. Coverage details often change annually. Too often, patients are unaware of these changes, so case managers must investigate more thoroughly.

Editor’s note: This article is adapted from an article in the November Case Management Monthly published by HCPro, Inc.

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