
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 ventilator 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 ventilator 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