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Insurance Authorizations: How to Get the Home Health Care You Need, When You Need It

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At age 88, Mrs. J. has lived in the same Brooklyn neighborhood for more than a quarter century. A few months ago, she was taken to the hospital with an infected diabetic ulcer on her foot. It was the second time she'd been hospitalized this year, and on this occasion, her physicians had to amputate two of her toes. Afterwards, she spent several weeks in a rehabilitation facility before returning home to her third-floor walk-up apartment.

Because Mrs. J. lives alone and was unable to manage the two flights of stairs on her own, she was essentially homebound and totally dependent upon her selected home health care agency for assistance. She'd been told at her rehab facility that a nurse would be checking on her, and that she would also be provided with a home health aide (HHA). That was on Friday, the day she was discharged. Then came a call and a telephonic assessment from the home care agency, explaining that because of a communications glitch with Mrs. J.'s insurer (a physician had not yet filed paperwork), her nurse wouldn't be there until Wednesday. The nurse showed up as scheduled, and a home health aide came that same day -- but for Mrs. J., the stressful five-day wait felt like an eternity.

While our health care system continues to evolve, situations like this are unfortunately bound to happen, though lapses in care are never "okay." In the interim, home care agencies like the not-for-profit Visiting Nurse Service of New York where I work, are developing new practices and working with payers and providers to help prevent service gaps. As the industry moves forward, there are also steps that patients and their families can take on their own to avoid or minimize potential problems. Following are some tips to help you and your loved ones navigate the system as VNSNY and other health care organizations work to make such delays a thing of the past.

Prior-Authorization: The Key that Opens the Door to Care
The important thing to understand about any home health care service -- whether it involves home visits from a nurse, a physical therapist or a home health aide -- is that unless you're planning to pay for all of the costs out of pocket, your insurance company must sign off on coverage of the prescribed plan of care before any home care services are provided. This is how insurance companies, including Medicare and Medicaid, make sure that reimbursed services go to patients who truly need them, and that these patients are given the right services for a medically appropriate period of time.

Normally, the home care agency handles the entire authorization process, leaving the patient free to concentrate on recovery. When this system works smoothly, everyone is happy. But if there's a hiccup -- if a form doesn't get submitted on time, or an insurer is slow to respond, or the home care agency's request doesn't fully address the patient's needs -- then the result can be delayed or interrupted care. To keep the process on track, here are a few things to keep in mind if you or someone you love relies on home health care services.

Your Personal Checklist for Key Touchpoints in the Authorization Process
There are three basic steps in the initial authorization process, which can vary from plan to plan: 1) verifying the patient's personal information, including who their insurer is and what benefits they are entitled to receive; 2) determining the patient's home care needs; and 3) submitting a request for those services to the insurance company and waiting for the request to be approved.

1) Verification: Make sure your home care agency has your personal and insurance info.
The verification process should be straightforward -- it basically requires that the home care agency touches base with the insurer to confirm the patient's name, address, and type of insurance plan. This can be done electronically in seconds with Medicare and Medicaid, using their websites; many home care agencies and private insurers have been moving to a similar online verification process. For this step to go smoothly, the home care agency needs all of your personal and insurance information upfront. If you or a loved one are in the hospital and plan to use home health services once you arrive home, the first thing you should do is make sure the home care agency has all this information in hand.

2) Determining your home care needs: Make sure your home care agency has your complete medical records, and that you and your doctor are informed of -- and sign off on -- the home care plan in advance.
Determining what home care services you or your loved one will initially require is done by the home care agency's intake nurse in consultation with your insurer and your acute care medical team. The most important thing here is that the requested services address the patient's immediate care needs. If additional services are needed, or are likely to be needed in the future, the agency has protocols in place for requesting these -- a process I'll discuss more in a moment.

These days, the amount of home care a patient receives -- including the number of home visits from a nurse and/or rehabilitation therapist, and the degree of home health aide assistance needed -- is decided largely by formula, depending on established standards of care related to the patient's diagnosis or condition. If the home care agency feels that the standard formula isn't enough for a given patient -- for example, if a patient has multiple medical conditions that may require extra nursing visits to stabilize -- then the agency can lobby for more coverage. This may mean conversations with physician and insurance carriers.

The key here is to be sure the home care agency has your complete medical records, and that you and your physician are informed in advance about the home care plan the agency will be recommending, and understand it fully. If you or your doctor feel the care plan isn't sufficient, then you should discuss this with the home care nurse as soon as possible -- before you leave the hospital if possible -- in order to avoid delays in your start of care.

3) Getting your home care request approved: Check with your home care agency before you leave the hospital to see where authorization stands and when your first home visit will happen.
The last part of the authorization process -- submitting your care request to the insurer and getting it approved -- is where holdups can commonly occur, simply because of the bureaucratic steps involved. Most large home care agencies and insurers have been working to streamline this process through improved communication and the use of evidence-based home care protocols, and in many cases authorization can now be obtained quickly -- often within hours, or at most a couple of days.

Still, if you or a loved one are being discharged home and want to be sure that care is in place when you get there, I advise checking with your home care agency's intake staff before leaving the hospital to see where the authorization process stands and when your first home visit will occur. And remember, if a patient has multiple chronic conditions, whether they're directly related to the current diagnosis or not, it's a good idea to bring this to the attention of the intake nurse and/or home care manager right away. That way, the potential need for extended or additional care will be included in their medical record. You should also make sure you know exactly how to contact the agency should problems occur down the road.

If the authorization process is slowed up for some reason, ideally your home care agency will reach out to let you know what's going on. But if you arrive home and still haven't heard when your first home visit will take place, you should call your home care agency for an update. If the agency says that your insurance company hasn't responded to the authorization request, then you're completely within your rights to call the insurer and ask the reason for the holdup. Again, the sooner any glitch in the system is addressed, the faster it will be resolved, and the sooner you'll start getting the care you need.

Ongoing Authorization: When You Need Additional Care to Aid Your Recovery
If your home care agency's initial request for home care services turns out to be insufficient -- for example, if they've requested three home sessions with a physical therapist, but your parent is still having trouble walking and needs several visits more -- then the agency will have to file what's known as an "ongoing authorization" request with your insurer, asking for additional covered visits. This involves a whole new round of documentation, including a report on your progress from the home care clinicians treating you.

Since this brings a new risk of potential delays, it's critical that you identify any need for additional services as early as possible. Again, it helps to stay in close communication with your home care team throughout this process. If additional care appears necessary, you should check with the agency to be sure the ongoing authorization request is submitted promptly, if and when additional care appears necessary. Your physician may also be a helpful resource here.

When all else fails. If you do hit that proverbial stone wall, you'll need to take it up with your insurance company. Fortunately, there are appeal procedures in place that can help. One thing that's important to realize is that while those of us who work at home care agencies are determined to give our patients all the services they need, if we supply services that haven't been authorized, then we risk being penalized for lack of compliance with regulations. When the financial burden of providing unauthorized services causes a top-notch home care agency to go out of business -- which has been known to happen -- it is everyone's loss.