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Elizabeth
Member
USA
5 Posts |
 Posted - 06/23/2004 : 12:41:40 PM
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I have experience in Medical and Psychiatric Case Management and Discharge Planning. I work prn for a large inner city hospital and find multiple patients with dual diagnoses. In providing DC planning I have little trouble obtaining authorization for f/u services if the condition being treated is medical but when I try to get follow up services based on a psych diagnosis I seem to end up spinning my wheels, running around in circles, repeating myself over and over and still finding an unpredictable outcome.
I recently had a patient with bipolar disorder - who has a history of homelessness but he was currently living independently in a small apt. near his family and attending rehab through Goodwill Industries. He even had a part time job at a local grocery store- which actually provided him with insurance benefits. He was hospitalized with a relapse of his alcoholism - and after stabilizing we wanted to get him some inpatient psych care to stabilize his psych medications and get him back on track with his alchohol rehab. He had been very ill - so we didn't think he should go home directly and his family was out of town on an extended trip...perhaps this precipitated his excessive drinking episode. Anyway, we tried and tried to get auth for a short inpatient stay - and got nowhere. Out of the blue I was providing UR info to one of the nurses and ended up telling this patient's long sad story. She gave me auth for a 3 day inpatient psych stay. As it turned out it was just what this patient needed to get him back on track.
But what an ordeal. Majorly time consuming.
Any ideas on how to expedite this variance in interpretation of patient needs???? Please Help.
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Edited by - Elizabeth on 06/23/2004 12:55:35 PM |
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Leslie
Member
USA
22 Posts |
Posted - 08/03/2004 : 2:50:17 PM
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In a situation like this it is intuitive that without appropriate support this patient will end up back in the hospital. However, insurance companies rarely authorize services based on intuition or common sense. They will respond to a good cost-benefit analysis though. How much will it cost them if he goes home, starts drinking again, and is readmitted for an acute care stay? Throw in an ER visit or two perhaps. How much will a short medication-adjustment mental health stay cost them?
Ask for their written criteria for admission for mental health. Present the patient's situation in relation to the criteria (eg: "he meets your x and y criteria based on....").
In my experience, most payers use different staff to manage medical and mental health benefits. Chances are you are talking to medically-oriented staff. In this situation I would ask to be transferred to their mental health division, or request Case Management services, since the patient has complex needs. A payer-based CM can cut through their red tape much faster than you can.
Also, if I find myself going in circles with a payer, I don't hesitate to work my way up their chain of command. If you haven't made progress with your contact person in 2 interactions, it's time to move it up the ladder. If that still doesn't work, then move it up your ladder (have your boss call their boss, or the MD call their medical director, etc.)
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urtoo
New Member
USA
3 Posts |
Posted - 01/12/2006 : 2:52:33 PM
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always utilize the area programs... there is usually an indigent grant or program for ongoing care... half way homes and sober houses are also handy... check out sober.com it has great listings... Most importantly keep talking about these issues and write your congress persons... there are a lot people in the same boat and something needs to be done... thanks to all who are really trying to help ours with minimal resources...
Trish Wyland
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Variance in Interpretation
