Dual Eligible Patients: Why did you just get a medicare denial?

CMS’ Financial Alignment Initiative is not only creating reimbursement nightmares for providers, including home health agencies, but also forcing patients to find alternate care at a moment’s notice.  In 11 states including, California, Illinois, Massachusetts, Michigan, Ohio and Virginia, patients and providers often find themselves facing a fear of the unknown.

What is this unknown? The patient’s insurance coverage: is it traditional Medicare or is it now a Managed Care plan?  In the 11 states who are participating in the CMS test, as directed by none other than the clearly thought out, very popular, and extremely rewarding legislation known as ObamaCare, patients often find out that their insurance has been changed without their authorization.  While this doesn’t affect all Medicare beneficiaries in the 11 states, it does affect a small minority of dual eligible patients – those who qualify for Medicare and Medicaid.

The biggest concern among providers and patients is the cryptic and short-notice warning given patients who are automatically being moved into Managed Care plans.  Sometimes without any notice at all, patient’s insurance suddenly becomes a Managed Care insurer, cutting off access to physicians, specialists and care that is needed, or is already in process.  For agencies, a sudden switch occurring during an open 60 day episode means terrible billing and financial consequences.

What can you do as a provider?  Educate.  If you are in an affected state, make sure your dual eligible patients coming onto service understand that their current access to physicians and home health services could be in danger if they receive any type of communication from their state’s Medicaid authority.  Informing patients that inaction could result in serious consequences is something that agencies must do to protect themselves and their patients.

Creating educational material that can be placed in admission packets is one way to keep patients reminded and on-notice about a potential change.  Be sure to reference the name of the Medicaid authority that may be sending them these notices.  Make sure your patients know what the letterhead will look like and what some of the terminology might be that they need to look for.

On your end, running your patients through the Medicare system once a week to review eligibility can also alleviate any billing issues when it’s time to send that final claim.

Patients do have the choice to opt-out.  But the patient must make the call – not the agency.

 

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