Oasis Point Rehabilitation Hospital

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Admissions Process & Insurance Guidelines

This comprehensive guide outlines the admissions process for Oasis Point Rehabilitation Hospital, including liaison responsibilities, insurance verification procedures, and authorization requirements. Following these guidelines ensures a smooth transition for patients while maintaining compliance with insurance requirements.

Liaison Responsibilities

  1. Oasis Point receives a referral from the hospital, case manager or a referral partner requesting the patient assessment for Inpatient Rehabilitation
  2. With the initial contact with every patient, the Liaison should obtain the most recent copy of their Medicare card from the patient and/or family member who is the insurance policyholder. When requesting a copy of the card, make sure that you receive a copy of both the front and back of the card. A copy of the patient's photo identification required for verification.
  3. Ask the patient if they have a secondary insurance:
    • If the answer is no, then nothing else is required
    • If the answer is yes, obtain a copy of the card (both front and back) from the patient, family member and/or the policyholder.

Insurance Approval Process

  1. Verify patient data – name, date of birth and/or sex is correct when checking eligibility. If something is wrong with what was entered, that field will turn red/bold.

    Example: Liaison states patient is 63 years old, but insurance verification states the patient is 53 years old.

    If there is a discrepancy with the information in the pre-admit package and the insurance verification, the patient is the only person that can update that information with their policy.

Key Definitions

Medicare Part A (hospital insurance)

Benefit period: The way that Original Medicare measures a patient use of hospital and skilled nursing facility (SNF) services.

A benefit period begins the day a patient admits into an inpatient hospital or SNF. The benefit period ends when the patient hasn't received any inpatient hospital care (or skilled care in a skilled nursing facility) for 60 days in a row to qualify for a new benefit period.

The patient must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.

Remember: Medicare only covers a limited number of hospital days and skilled nursing care within each benefit period. The patient gets up to 90 hospital days (not counting your 60 lifetime reserve days).

Referral

A recommendation of a medical or paramedical professional. The term "referral" can refer to the act of sending to Oasis Point. The referral obtained from the referring physician stating "Referring the patient for Inpatient Rehabilitation Hospital." The liaison goes to the hospital, medical office, clinic, or home to assess the patient.

The liaison requests the following documents:

  1. A medical order or script stating "Referring to the patient for Inpatient Rehabilitation Hospital."
  2. The last 3 days of medical notes:
    • Medical
    • Consults
  3. Procedures, including:
    • PICC line
    • Dialysis
    • Modified Barium Swallow
  4. History and Physical
  5. Consults
  6. Emergency Room notes
  7. Graphics
    • Vital signs
  8. Radiology
  9. Laboratory
  10. Culture results
  11. Therapy notes
    • Physical
    • Occupational
    • Speech (MBSS report written by the SLP if applicable)
    • Respiratory
  12. Discharge Summary (weight bearing status)
  13. Current MAR – Medication Administration Record
  14. Discharge Plans

Authorization

A review process to determine medical necessity of medical health service. A decision by a health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. The health insurance or plan may require preauthorization before a patient is admitted to Oasis Point Rehabilitation Hospital. Health insurance companies use the prior authorization or pre-approval process to verify that a service is medically necessary. The patient is responsible for their deductible.

Acute Hospital days (Co-Insurance)

Part A covers your inpatient hospital services. Generally, this means the patient pays a one-time deductible of $1,340 per benefit per calendar year. Generally, a patient may have enrolled in a coinsurance that would pay the deductible.

Coinsurance days (Co-Day)

Medicare Part A covers up to 60 additional lifetime reserve days. The Co-Days used after the 60 Acute days exhausted and now on the 90th day as a hospital inpatient during a single benefit period. Reserve days are not renewable and can be used only once during your lifetime.

Lifetime Reserve days (LTR)

Medicare Part A covers up to 60 additional lifetime reserve days. The LTR days used AFTER the patient has reached 90 days as a hospital inpatient during a single benefit period. Reserve days are not renewable and can be used only once during your lifetime. A coinsurance amount equal to one-half of the inpatient hospital deductible applies to lifetime reserve days.

Original Medicare Patient Cost

$1,340 deductible for each benefit period.

  • Days 1-60: $0 coinsurance for each benefit period.
  • Days 61-90: $335 coinsurance* per day of each benefit period.
  • Days 91 and beyond: $670 coinsurance** per each "Lifetime Reserve Day" after day 90 for each benefit period (up to 60 days over your lifetime). Beyond lifetime reserve days: patient assumes all costs.

* – If the patient has secondary insurance, the coinsurance payment* covered by the secondary insurance, for example, Aetna, AARP -- * depending on individual policy

** – Oasis Point Rehabilitation Hospital policy when admitting a patient in LTR, the family or patient must sign an agreement, that will be issued by our billing department, acknowledging the use of LTR and payment arrangement.

Insurance Verification Procedures

Medicare

  1. Check MyAbility or Thrive for coverage and days. When checking for coverage and days, set the parameters from date of admit up to six months.
  2. Once the approval is received:

    Remember: A benefit period begins on the day of patient admission and ends when patient has been out of the hospital for 60 days in a row. If a patient has left the hospital on a particular day and then is readmitted before 60 days from last discharge from the Acute hospital is up, the patient is still within the same benefit period. But if the patient goes back to the hospital after that 60th day, the patient then qualifies for a new benefit period. The difference between the two has an impact on your costs.

    1. Look at the days of inpatient rehabilitation days in MyAbility:

      To calculate the Medicare Co-Insurance, Co-Day, and LTR, you must subtract the number of days shown in MyAbility from the number of patient current hospitalized days. Remember, the current hospitalization stay will not be included and the available days showing are NOT accurate.

      Admission Discharge Days used Remaining Benefit Days
      Acute Hospital
      01/01/2018      		 01/10/2018 10 50-30-60
      Acute Hospital
      03/01/2018      		 04/5/2018 36 14-30-60
      Inpatient Rehab
      04/05/2018      		 06/02/2018 57 0-0-47
    2. If the patient is in their Co-Day days because of the 60 acute days are exhausted, Administrator approval required for patient admission.
    3. If the patient has used all 60 acute days and 30 Co-Day days, the patient will be going into their Life Time Reserve (LTR) Days. The administrator must consult the CFO for financial approval prior to the patient's admission.
    4. At Oasis Point Rehabilitation Hospital it is our policy, that we do not use the patient's LTR days because once they are used, they do not regenerate.
    5. Prior to the admission of a patient in LTR days, an agreement must be completed by the patient or patient representative that they are approving the use of the patients LTR days. The agreement can be obtained from the billing dept. The patient and or patient representative must be provided education on the use of the LTR days and the patient's remaining insurance benefits prior to signing the agreement.
  3. Look for Medicare Advantage Alert
    1. If there is a Medicare Advantage Alert, then authorization is required from Medicare Advantage plan.
    2. If approved, obtain the policy holder's Medicare number and enter into eRehabdata
      1. The patient's approval obtained from the insurance maybe received via verbal or written form (which will vary with the insurance companies). Obtain the authorization number from the provider
        1. Upload into eRehabdata, and label "insurance authorization."
        2. Give a copy of the patient authorization to Case Manager
        3. Any additional days requested during the patient's stay, Oasis Point Rehabilitation Hospital's Case Manager, will apply for further approval including the last day of the stay
  4. Check on MyAbility for any open segments
    1. If no open segments continue with the admission process
    2. If there is an open segment, check on the open segment if the admitting diagnoses are related to the admission
      1. If the open segment is not related, then continue with the admission process
      2. If the open segment is related to the admitting diagnoses, then authorization is required from the open segment. The open segment maybe a workman's compensation or automobile accident.

Medicare Advantage

  1. Check MyAbility for coverage. When checking for coverage and days, Set the parameters from date of admit up to six months
  2. Once the eligibility is received:
    1. Patient has a Medicare Advantage plan
      1. The eligibility will state which Medicare Advantage Plan:
        • WellCare – submit for authorization by phone or form with medical records. Note: Patient would need Out of Network Benefits for admission.
        • Peoples Health – submit for authorization by phone or form with medical records.
        • Blue Cross Advantage – submit for authorization by phone or form with medical records.
        • Allwell – submit for authorization by phone or form with medical records.
        • Humana – submit for authorization by phone or form with medical records. Note: Patient would need Out of Network Benefits to for admission.
        • Aetna Medicare – submit for authorization by phone or form with medical records.
        • Coventry – submit for authorization by phone or form with medical records.
        • Vantage Health – submit for authorization by phone or form with medical records.
        • United Healthcare – Identify if the patient has commercial or Medicare Advantage Plan –
          1. Submit for authorization by phone to the appropriate plan first (obtain pending reference number). The reference number is not an Authorization number for admission; it is only a reference on the case.
          2. Fax clinical information (prescreen, and medical records from the referring facility or physician) to the Nurse intake line with Reference number written on fax cover page.

Medicaid

  1. Check MyAbility for coverage. When checking MyAbility for coverage, automatically enter service date as today's date for coverage
  2. Look if the patient has either Straight Medicaid or Bayou Health Plan

    Remember: when verifying Bayou Plans be sure to identify what type of benefits the patient has with that plan: Mental, Dental Medical

    WARNING: if the MyAbility lists – Dental, Mental and NO MEDICAL is listed, then the patient has STRAIGHT MEDICAID MOLINA – no authorization required.

    1. If the patient has Straight Medicaid, no authorization is required.
    2. If the patient has Bayou Health Plan, authorization is required
      1. The eligibility will list the Bayou Health Plan:
        1. AmeriHealth – submit for authorization by phone or form with PreScreen & medical records.
        2. Aetna Better Health – submit for authorization by phone or form with PreScreen & medical records.
        3. United Healthcare Community – submit for authorization by phone FIRST, Fax clinical information (prescreen, and medical records from the referring facility or physician) to the Nurse intake line with Reference number written on fax cover page
        4. Healthy Blue – submit for authorization by form with PreScreen & medical records.
        5. Louisiana Healthcare Connections – submit for authorization by phone or form with PreScreen & medical records.

Commercial Insurance

Aetna, Cigna, United Healthcare, Coventry, Blue Cross Blue Shield, etc.

  1. Check MyAbility for coverage. When checking for coverage, MyAbility automatically enter service date as today's date for coverage.
  2. Check if the patient has alert,
    1. If the patient has Other Health Plan, the insurance is listed under the patient demographics.

Tricare For Life

  1. Verify the patient's coverage under their social security number or their spouse's. If the coverage is under the spouse, we need the spouse's social security number and date of birth.
  2. Check MyAbility for coverage. When checking for coverage, MyAbility automatically enter service date as today's date for coverage.

Authorization Documentation

For all insurance types requiring authorization:

  1. The patient's approval obtained from the insurance maybe received via verbal or written form (which will vary with the insurance companies). Obtain the authorization number from the provider.
  2. Upload into eRehabdata, and label "insurance authorization."
  3. Give a copy of the patient authorization to Case Manager
  4. Any additional days requested during the patient's stay, Oasis Point Rehabilitation Hospital's Case Manager will apply for further approval including the last day of the stay.