New York StateWide Senior Action Council Teach In November 21 2013 Nora Baratto ACM LCSWR Director Case Management Preparation is KEY Know your insurance read the definitions know coverage exclusions deductibles copays and provider network ID: 623966
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How to Have a conversation with Hospital Staff about your Status and DischargeNew York StateWide Senior Action Council Teach InNovember 21, 2013
Nora Baratto, ACM LCSW-R
Director, Case ManagementSlide2
Preparation is KEY!!
Know your insurance, read the definitions know coverage, exclusions, deductibles, copays and provider network
If you do not understand your insurance Call Senior Action council ,
local HIICAP program counselor
, Health care advocate to help you understand the terminology.
Have a power of attorney and health care proxy in place.
Keep everything in a file and update it inform
family of file in event of emergency.Slide3
Be an active participant in your Care
You are your own best advocate. If you are unable to advocate for yourself designate someone you trust …..Health care agent.
Ask to speak with your D/C planner immediately and inform them of what your expectations are relative to D/C.
Hospital staff including physicians are required to follow state and federal regulations cannot change Medicare rules i.e. we can’t make a patient an inpatient for three days
just
so they qualify for skilled nursing care.
Patient status is based on Medicare and hospital guidelines
.Slide4
Know your Right’s as a Patient – NYS DOH
“Your Rights” Booklet can be found at: http
://www.health.ny.gov/publications/1449.pdfSlide5
Right to know your patient status.
-
Observation status
is assigned when the physician needs
to
due further testing and evaluation to
make decision
if admission is required. Typically observation status is usually only for up
to 48 hours
-
Ambulatory Care
- outpatient surgery/procedure
-
Inpatient Status -Medical necessity
is what determines status. You need to be acutely ill and require the 24/7 expertise of physicians and RN continuous monitoring of a serious illness.
-
Custodial Care
(24 hour supervision that
does not
require RN monitoring) can be provided in another setting.
- Many consumers mistakenly think if they can’t care for themselves their insurance will cover. Slide6
Patient Right’s D/C Planning
Right to be actively involved in your d/c plan. if unable designated legal representative can act
Right to choose post acute providers of care.
Right to refuse D/C plan
Right to receive D/C plan in writing
Be informed 48-24 hours in advance of D/C in writing
Can appeal your D/C
through IPRO Slide7
Appeal Rights
If you are in observation status and the physician determines that you do not need to be admitted but you cannot return home. You would be issued an
admission denial
. You should appeal to your insurance company.
While waiting for the decision you will not be charged until a decision is made.
If an inpatient and you no longer need acute level of care you will be informed and can appeal. Once again you will not incur any charges until a decision is made.Slide8
You have the right to appeal decisions made by your doctor, hospital staff or your managed care plan:about when you are to leave the hospital;if you feel you are being asked to leave the hospital too soon;
if you believe you have not been given adequate or appropriate plans for your medical care and other services you may need after you leave the hospital;
or
if needed services are not in place.
The law requires that you receive advance notice
in writing
telling you:
the date the physician and/or hospital plans to discharge you;how to appeal if you wish to remain in the hospital; and
a special number to call with any problems related to leaving the hospital.
For Assistance/Help
There is an Independent Professional Review
Agent
(IPRA) for your area and your insurance coverage. Should you need assistance/help from the IPRA, the hospital will provide you with a phone number/ person to contact. See
the Glossary
for more information.
For Medicare Patients OnlyIf you feel that you are being asked to leave the hospital too soon and have not received advance notice telling you when to leave the hospital, ask for your discharge notice (called "The Important Message from Medicare about Your Rights"). If you are in a Healthcare Maintenance Organization (HMO), you should also request "The Important Message from Medicare about Your Rights". You must have this written discharge notice in order to appeal the physician's and hospital's decision about when you are to leave. See an "Important Message from Medicare about Your Rights" for a complete explanation.For Managed Care PatientsIf you are a patient enrolled in an HMO or managed care plan, first request/submit an expedited appeal to the HMO or plan's utilization review committee if you feel your benefits are unfairly limited or denied, or you are being asked to leave the hospital too soon, or that medically necessary services are inappropriately excluded from your coverage. If you are not satisfied with the outcome of that appeal request, you may contact the New York State Department of Health by calling: 1-800-206-8125.The Managed Care Law of 1996 amending Public Health Law 4408, Disclosure of Information
If You Think You Are Being Asked to Leave the Hospital Too Soon. . .Slide9
Appealing a Discharge or Quality ProblemIPRO —This is the quality improvement organization contracted by the federal and state government to review the hospital's care provided to Medicare and Medicaid patients in New York State.
Appealing a discharge :
Contact if you believe you are being discharged too soon from the hospital. Call toll-free at 1-888-880-9976.
For complaints about the quality of hospital care you can call the Medicare Hotline toll free at 1-800-331-7767.Slide10
Know your D/C options
Skilled Home Care - short term need MD order
Case Management Services
Short term rehabilitation in skilled nursing facility
Respite services
Community program local office for aging and senior services
Mobile meals, LifelineSlide11
Tips for success
Please focus on “how you can prevent coming to the hospital”
have an in home assessment and develop a plan . If you see a decline in your health see your physician and ask for homecare to assess you
If you end up in the hospital request a meeting with your D/C planner to develop a plan of care.
Request to see a patient representative in the hospital or a social worker if you feel your needs are not being met. Slide12
Questions