Traditional Medicare

  • DRG-based
    • A clear and definite transitional care plan aide’s clinical acceptance
  • PIC Compliance
    • Minimum of 3 midnights of ICU/CCU level care or 96 hours on a vent in the short-term acute care hospital (STAC)
  • Medical Complexity/Acuity
    • Critical Care Services
    • Pulmonary Services
    • Complex Wound Care Services
  • Rehab Need
    • Patient’s current functional level is below baseline norm
    • Patient would benefit from PT, OT, ST but
      • 1. Is unable to participate at the level necessary to qualify for SNF or IRF or
      • 2. Is unable to access SNF or IRF due to medical complexity issues

Managed Medicare

  • DRG-based
    • A clear and definite transitional care plan aide’s clinical acceptance
  • Varying Pre-Authorization Requirements Depending on Brand (Aetna vs. Humana, etc.)
  • PIC Compliance (Differs from Traditional MCR)
    • May require 21 days on a vent before considering LTAC
  • Medical Complexity/Acuity
  • Rehab Need
    • Patient’s current functional level is below baseline norm
    • Patient would benefit from PT, OT, ST but
      • 1. Is unable to participate at the level necessary to qualify for SNF or IRF or
      • 2. Is unable to access SNF or IRF due to medical complexity issues

Medicaid

  • Fee for Service-based reimbursement
    • Discuss expensive meds or treatments or combos thereof
  • Doesn’t require Post Intensive Care (PIC) compliance
  • Will require Pre-Authorization if Managed Medicaid such as Denver Health MCD or Rocky Mountain MCD.

Commercial

  • FFS-based
  • Doesn’t require PIC compliance
  • In all cases require Pre-Authorization
  • Kaiser needs pre-auth number before our referral
  • 24-48/72 hrs to receive auth (give CL 3 days notice you want auth going)

Workman’s Comp

  • Need LOA – letter of agreement with financial deal made
  • Need CM contact info

Department of Corrections

  • Need LOA – also covering compassionate release situations
  • Give contact for prison CM
  • Prison release dates
  • Crossing state lines
  • Compassionate release/lifelong parole-is there a secondary payer
  • DC Plan to jail, accompanied by guards to hospital