Opening and Closing Reports

Opening and closing reports are data submitted to Corporate Teams regarding the census of how many patients are in bed in each facility. The opening report provides actual data and needs to be submitted before 10:00 a.m. The closing report, on the other hand, is a projection of data and should be submitted before 5:00 p.m. These reports are essential for keeping track of facility occupancy and ensuring proper planning and management.

Win Office EOD Report

The Win Office EOD (End of Day) report is designed to keep track of and be accountable for the referral processing status. It tracks the number of referrals received, authorized, approved, denied, and the reasons for denial on a given day. The report includes details about the total referrals received, total authorization requests, total approvals, pending requests, total denials, and the reasons for denial.

Processing Referrals

• Check different portals for upcoming referrals from various hospitals.

• Process the referrals promptly and assign them to your name to indicate that you are handling them.

• Review the clinical and financial light system of the referral to determine acceptance criteria (GREEN - immediate acceptance, YELLOW - needs further review, RED - denial due to red flags).

• Send a medication quote to the pharmacy and CC the facility for approval.

• Verify primary and secondary coverage through portals or by making necessary calls.

• Email referral teams with details such as primary and secondary coverage, diagnosis, disposition, medical quote, and health provider (HP) information.

• Attach all processed documents like hospital records, financial screens, ID cards, and level 1.

  • • If the medical quote is pending, indicate "pending." In case of higher medication costs, alert the involved facilities for determination or possible request to curve out.

    • Enter all patient information, demographics, resident contact, and processed paperwork into the CRM (Point Click Care).

    • Ensure that all information is saved properly.

    • These reports and processes are crucial for maintaining accurate and up-to-date information about the facilities' census, referral processing, and patient admissions. Properly managing this data helps in providing effective care to patients while maintaining compliance with insurance coverage and financial requirements.

Referrals

• Referrals have a limited amount of time to reply.

• Key points to consider during referrals

o   Verify coverage

o   Verify benefits available

o   Review for discharge issues and potential for long-term stay

o   Send to the clinical team for approval

o   Obtain authorization

o   Arrange admission

Referrals Process Overview

Step 1: Referral Email Assessment

o   A referral email is sent from the WIN Office to key stakeholders, including the Administrator, Director of Nursing (DON), Admissions Team, and Regional Business Office Team.

o   The WIN Office highlights pertinent questions in the email that can impact billing, discharge planning, and clinical decisions.

o   The responsibility of promptly answering these questions falls upon the Liaison/Admissions Director, who should respond within the same email chain.

Step 2: Yellow/Red Light Referrals

o   In this step, referrals may be categorized as Yellow or Red Lights.

o   For Clinical Referrals: The DON assesses the clinical aspects and writes either an approval or denial within the same email chain.

o   For Financial Referrals: The Regional Business Office contacts the Administrator separately, providing suggestions on handling high-risk financial referrals.

o   If the Medication Quote is deemed high, the Admissions Director collaborates with the DON and Administrator to determine the next steps.

Step 3: Final Decision within 20 Minutes

o   All Yellow and Red-Light referrals are subject to review by the Administrators.

o   A final decision is made by the Administrators within a 20-minute timeframe.

o   If needed, communication can be sent back to the WIN Office for the approval of denial.

Referral Processing Workflow

Step 1: Referral Receipt and Status Update

o   Receive the referral.

o   Update the Referral Portal to indicate that the referral has been received.

Step 2: Initial Processing

o   Send the Medication Quote.

o   Send an email containing recent medications from the Hospital pharmacy and co-facility.

o   Begin the processing immediately.

o   Review the clinical aspects of the referral.

o   Process the financial aspects, including primary and secondary coverage, through phone and Pal.

Step 3: Further Processing

o   After initial processing, proceed with the following:

o   Review primary and secondary coverage through phone and Pal.

o   Screen for any discrepancies.

o   Ensure secondary coverage through Pal and phone.

Step 4: CRM Entry and Verification

o   Access the CRM (Customer Relationship Management system).

o   Verify insurance information in Dorado.

o   Upload all relevant screens and paperwork into the "miscellaneous" tab in the CRM.

o   Enter CRM details, including demographic information, hospital information, and contacts.

Step 5: Confirmation and Documentation

• Once all processing is complete:

o   Send a Referral Email containing all relevant screens.

o   Provide a quick snapshot of the referral in the body of the email, including Primary/Secondary information, Disposition, and Diagnosis.

o   Attach all necessary documents to the email, such as hospital records, financial screens, ID cards, and level 1 documents.

o   The Admissions Director sends the booking to Win.

o   If requested, obtain authorization.

o   If requested, obtain a carve-out agreement.

This structured workflow ensures that referrals are received, processed, and documented systematically, enhancing the efficiency and accuracy of the admissions process

Referrals Email Template

• DIAGNOSIS: 

• PRIMARY PAYER: 

• CO-PAY: 

• CO-INS: 

• DEDUCTIBLE: 

• OOP: 

• DAYS AVAILABLE: 

• SECONDARY PAYER: 

• MEDICAID: 

• SW: 

• ATTENDING MD: 

• MED QUOTE: 

• HISTORY: 

Coverage

·        Many people have coverage through various insurance carriers.

·        Different types of coverage

o   Medicare Traditional: No authorization needed, maximum 100 days per spell of illness.

o   Managed Medicare: Authorization needed, follows Medicare guidelines, but the stay is managed by the insurance case manager.

o   Commercial Insurance: Benefits through employer or individual policy, authorization needed, benefits vary by plan, and the stay is managed by the case manager.

o   Medicaid Fee for Service: Benefits through the state, limited to custodial care for long- term Medicaid residents.

o   Managed Medicaid: Benefits managed by MLTSS carrier, coverage may be custodial, respite, or skilled/SAR.

Traditional Medicare

·        100 days of coverage per spell of illness, maximum, and requires continuous skilled need.

·        Additional coverage requires 60 days of wellness (no skilled care either in a center or at home and no hospitalization).

·        Physician recertification necessary indicating skilled need.

·        Length of stay is determined by the need.

·        Custodial care is not covered.

Managed Medicare

·        Managed Medicare has two types: HMO and Medicare Advantage.

·        Both plans require authorization, skilled need, and reimburse at different levels of care.

·        Requires in-network provider participation.

·        Both plans require physician certification and clinical updates, and the length of stay is determined by the case manager.

·        Most plans have copay but are usually pre-set amounts.

Commercial Insurance

·        Commercial plans are many and varied, so it's important to ask for clarification of benefit days allowed and available.

·        Some plans are based on the calendar year, and others are based on the spell of illness.

·        Most plans have copay, deductible, and out-of-pocket expenses.

·        If coverage is through an employer, it's important to confirm that the benefits are still in place through COBRA or family leave.

·        Rates are either based on contracts for in-network carriers or single case agreements for out-of- network carriers.

Traditional Medicaid

·        Traditional Medicaid only applies to long-term residents and is only for custodial care.

·        Residents covered by long-term Medicaid in another center and transfer to a new center will be enrolled in an MLTSS carrier.

·        Long-term stays require income to be turned over, and reimbursement is based on the state rate, which is different at each center.

Managed Medicaid

·        Managed Medicaid plans are provided by five carriers in NJ, with short-term, respite, and long- term benefits.

·        Approval for long-term stays requires clinical approval by the MLTSS case manager, and benefits will require conversion at the county board of social services.

·        Coverage for skilled and SAR are at different levels and reimbursed per contract.

·        Long-term stays require the resident's income to be turned over and are reimbursed at the state rate.

 Long-term Stays

·        A checklist is used for evaluating long-term stays, considering discharge issues and potential long-term care needs.

·        Residents must have a legal POA or guardian if they are not competent to handle their affairs for smooth transitions.

·        Admission paperwork checklist and agreement must be completed and uploaded into PCC along with other supporting documentation.

·        Cooperation with the finance team is essential for successful admissions and proper planning of care and safe discharge.

Admission Paperwork

The admission process requires completing a checklist and agreement that must be uploaded into PCC (Patient Care Coordination) along with various supporting documents. The necessary paperwork includes, but is not limited to:

o   Signed agreement

o   Legal power of attorney (POA) or guardianship documentation

o   Hospital records

o   All insurance cards

o   Insurance authorizations

o   Benefits verifications

o   PAS/EARC PAS (Patient Assessment Instrument/Eligibility and Enrollment Request for the Institutional, Outpatient, or Home and Community-Based Services under the Medicaid Program)

o   Financial application if the resident is private pay or applying for long-term Medicaid (MA) coverage.

Coordinating with Finance Team

The key to a successful admission process is collaborating with the finance team and preparing all relevant information before admission. Once a person is admitted to the center, they become the responsibility of the center and cannot be discharged into an unsafe environment. It is crucial to be aware of the resident's prior living arrangements and financial circumstances as this will enable the center to develop a proper plan of care and ensure a safe discharge when needed. Proper financial planning and understanding the resident's insurance coverage are essential to provide the best care possible while maintaining their safety and well-being.

How to Add Referral to CRM

https://pointclickcare.zoom.us/recording/share/9VhsDvxTpK8ITzuo0GCMTp-j6dNpxx--

NdjZ6scT3vGwIumekTziMw?startTime=1568898380000