How to Get the Home Health Care You Need, When You Need It|Marki Flannery

At age 88, Mrs. J. has lived in the same Brooklyn neighborhood for more than a quarter century. A few months ago, she was taken to the hospital with an infected diabetic ulcer on her foot. It was the second time she'd been hospitalized this year, and on this occasion, her physicians had to amputate two of her toes. Afterwards, she spent several weeks in a rehabilitation facility before returning home to her third-floor walk-up apartment.Because Mrs. J. lives alone and was unable to manage the two flights of stairs on her own, she was essentially homebound and totally dependent upon her selected home health care agency for assistance. She'd been told at her rehab facility that a nurse would be checking on her, and that she would also be provided with a home health aide (HHA). That was on Friday, the day she was discharged. Then came a call and a telephonic assessment from the home care agency, explaining that because of a communications glitch with Mrs. J.'s insurer (a physician had not yet filed paperwork), her nurse wouldn't be there until Wednesday. The nurse showed up as scheduled, and a home health aide came that same day -- but for Mrs. J., the stressful five-day wait felt like an eternity.While our health care system continues to evolve, situations like this are unfortunately bound to happen, though lapses in care are never "okay." In the interim, home care agencies like the not-for-profit Visiting Nurse Service of New York where I work, are developing new practices and working with payers and providers to help prevent service gaps. As the industry moves forward, there are also steps that patients and their families can take on their own to avoid or minimize potential problems. Following are some tips to help you and your loved ones navigate the system as VNSNY and other health care organizations work to make such delays a thing of the past.Prior-Authorization: The Key that Opens the Door to CareThe important thing to understand about any home health care service -- whether it involves home visits from a nurse, a physical therapist or a home health aide -- is that unless you're planning to pay for all of the costs out of pocket, your insurance company must sign off on coverage of the prescribed plan of care before any home care services are provided. This is how insurance companies, including Medicare - - and Medicaid, make sure that reimbursed services go to patients who truly need them, and that these patients are given the right services for a medically appropriate period of time.Normally, the home care agency handles the entire authorization process, leaving the patient free to concentrate on recovery. When this system works smoothly, everyone is happy. But if there's a hiccup -- if a form doesn't get submitted on time, or an insurer is slow to respond, or the home care agency's request doesn't fully address the patient's needs -- then the result can be delayed or interrupted care. To keep the process on track, here are a few things to keep in mind if you or someone you love relies on home health care services.Your Personal Checklist for Key Touchpoints in the Authorization ProcessThere are three basic steps in the initial authorization process, which can vary from plan to plan: 1) verifying the patient's personal information, including who their insurer is and what benefits they are entitled to receive; 2) determining the patient's home care needs; and 3) submitting a request for those services to the insurance company and waiting for the request to be approved. 1) Verification: Make sure your home care agency has your personal and insurance info.When all else fails. If you do hit that proverbial stone wall, you'll need to take it up with your insurance company. Fortunately, there are appeal procedures in place that can help. One thing that's important to realize is that while those of us who work at home care agencies are determined to give our patients all the services they need, if we supply services that haven't been authorized, then we risk being penalized for lack of compliance with regulations. When the financial burden of providing unauthorized services causes a top-notch home care agency to go out of business -- which has been known to happen -- it is everyone's loss.