Managed Care World without Prior Authorizations is a Win-Win for...

Managed Care World without Prior Authorizations is a Win-Win for All Parties

Franklin Segura, Vice President of Managed Care, Centers Health Care

Franklin Segura, Vice President of Managed Care, Centers Health Care

In the world of managed care, when an individualized health plan gives a managed care company the go-ahead to admit with no authorization, or what some call a “Gold Card,” the overall notion is it is a win-win for all parties involved, especially the patient. But the “No-Auth” way of doing business is not a new idea of taking a patient’s case into home care, whereby the home care agency fully manages the case from beginning to end. While this case management methodology is gaining popularity during the COVID-19 era, it seems to be only a temporary method for most health plans to conduct business. A health plan structures a case to make it work systematically to fit the needs for them as well as the home care agency and the patient. That managed care plan can do things where it’s a win-win situation for all parties, but this individualized strategy is almost never a “one size fits all” scenario.

For example, a home care agency (Certified Home Health Agency or CHHA) can eliminate the need to call the health plan asking, “if they can accept a specific case?” which is an administrative and financial burden to both the health plan and the home care agency. The provider will manage the case without authorization, providing services the health plan would have authorized anyways, but this way, it is with no administrative burden. The notion of the provider asking for, “can we take this case?”, this is an administrative step that should be deleted. The end result is that the provider would fully manage a patient’s case with the same outcomes, just eliminating the authorization process of delaying care and keeping the patient/member out of the hospital.

If a patient with a wound needs a certain number of visits, such as three visits per week for the next three weeks, the responsibility of the CHHA is to fully manage the patient’s care. What could understandably happen is that the health plan can come back at the end of the patient case and say that they reviewed the case and it was decided that the patient did not need visits or homecare; they can then deny the “No- Auth” and the health plan and provider would review the case to determine if it was medically necessary. If it is determined that the provider accepted the case, and it was not medically necessary, the health plan would deny payment to the provider for the entire case. The provider accepts this risk and subsequently will learn to provide appropriate and medically necessary care without authorization in the appropriate clinical setting, whether it be a Skilled Nursing Facility or a patient home.

Typically, when a provider and health plan agree to go with the no prior authorization methodology, the health plan will require a monthly summary of the cases the provider has accepted. In the summary of cases, the health plan can review cases and determine if they were “inappropriate,” and the plan and provider would review together. The home care agency takes the patient out of the hospital quickly and services them within the community. It’s a saving for the hospital, the family is satisfied, especially during these COVID-19 times, and the patient is in their home receiving personalized home care. This is all instead of waiting in the hospital for the health plan to authorize home care for a safe discharge.

"Typically, when a provider and health plan agree to go with the no prior authorization methodology, the health plan will require a monthly summary of the cases the provider has accepted"

All of this is key for the safety of the patient during COVID-19, as well as after the COVID-19 pandemic subsides. The patient doesn’t want to be in the hospital, and families do not want or simply cannot visit their loved ones, which creates a mental strain on both the patient and their loved ones.

With “No-Auths,” the home care agency can get to the patient quicker, service them quicker, with the goal of altogether avoid re-hospitalization for the most part because they are being serviced upon discharge. Also, a patient who is released too quickly to the community without home care, and are awaiting services, is likely to end up back at the hospital. If this happens and, for example, the patient develops a new open wound, they are then waiting a number of days for a nurse to arrive, and during this time, the wound is getting worse, there’s a fear of infection, and re-hospitalization can very well happen, thus costing the health plan more money which could have been avoided.

The methodology of “No-Auths” has been around for some time, but health plans are embracing it more these days because it reduces cost but more important, the patient is being serviced upon discharge the same day or next by the home care agency. It wasn’t popular at first due to the health plans not wanting to give home care agencies free rein or “ownership” of a patient. This is certainly not the case because the health plan is still managing the home care agency when all said and done. It’s a win-win for everyone involved since the patient is being taken care of quicker at home designed by the home care agency, the administrative time-consuming back and forth calls, as well as the longevity of patient case reviewing, are eliminated through the “No-Auth” methodology.

It’s a full-course management approach being provided by the home care agency, being fully monitored by the health plan, during and/or after the patient’s hospitalized care, by the home care agency who is able to offer healthcare-services the patient needs during the process. “No Auths” is a methodology that puts the patient at the heart of his care and offers a major cost saving for all parties, including the safety aspects of not being in the hospital longer than needed during and post-coronavirus pandemic.

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