PRECODE
Yes/No
Yes/No
COBRA is not offered based on the size of the employer, church affiliation, or union qualification.
What is No (plan limit met)
sub-reason Clinic: The patient transfers out of the facility because there is only one doctor group rounding and he/she is dissatisfied.
sub reason right/wrong?
What is Wrong (sub-reason doctor)
During Open Enrollment patient's EGHP changed. The facility is now out-of-network. What is Sub-reason?
What is Contracting?
Pt was discharged from the clinic for behavior. Last TX 5/1/22, the patient had threatened PCT that someone will be waiting outside. This is after verbal abuse from the pt during other treatments. IC was aware of the pt's bad behavior.
What are details of escalation
Who should you include in a loss Escalation email?
What are, DVP, ROD, FA, SW, GIC
When coding a transfer out - you need to include the address of the clinic patient transferred to?
Right or Wrong
What is wrong: you only need the distance
Pt's plan no longer covers a SNF and pt elects for additional coverage
What is No (plan limit met)
Sub-reason premium payment: New pt 1/25/22 who was admitted with Managed Medicaid policy and had a cobra BCBS which pt canceled and stopped paying the premium 12/31/21; prior to starting DVA. Cobra showed active until 3/31/22. Pt preferred Managed Medicaid over cobra due to the cost of high premiums and OOP. COB 10/24.
sub-reason right/wrong
What is wrong (plan limit met).
Patient on Geisinger QHP and due to loss of income, when he reapplied for 2022, he was directed to Medicaid. Geisinger QHP policy termed 12/31/21 and patient now has Aetna Better Health. Leadership notified 12/15/21. What is the Sub-Reason
What is COB/SPD
The new pt is transferring out after learning the facility is not contracted with CIGNA. DVA contract termed 4/30 Pt's last tx is 5/25. IC escalated to field leadership on 5/15. Pt has no OON benefits, Pt was informed DVA is pursuing a SPA or OON Authorization.
IC reviewed DVA In-Network facilities with pt
The patient advised that they quit their job and pursing Cobra.
Dose this require escalation
What is no: unless you find that they aren't electing Cobra or QHP
You need to document if the clinic anticipates a patient return on a transfer out.
What is right
The patient drops coverage due to a lack of transportation benefits and new coverage offers transportation to dialysis
What is Yes (Insurance Change: transportation)
sub-reason COB: Post COB patient Medicare primary patient loses coverage and commercial is set as primary until Medicare is reinstated.
sub-reason Right or Wrong
What is wrong: correct code (Plan limit met)
QHP Patient obtains Government plan while on a QHP plan due to limited benefits and/or network
what is sub-reason
What is Network
Medicare is now primary due to patient meeting COB. Patient re-enrolled during July General Enrollment Medicare had termed due to nonpayment & EGHP refused to pay primary. FDODE 6/2018, COB 3/2021, Medicare A eff 10/2018 & B 7/1/2021
Beginning (July Medicare Enrollment)
The patient is retiring and is offered a PPO retiree plan or Medicare Advantage Plan and the patient chooses Medicare Advantage.
Does this require an escalation?
What is Yes: because they had an option for elect a PPO
You don't need to list the hospital the patient is in when coding a Transfer Out due to hospitalization?
Right or Wrong
What is wrong
Access to care under current coverage is too limited based on the patient's needs
Yes (Insurance Change: Network/Access)
sub-reason Plan limit met: Pt lost his job with Southwark Metal and coverage was termed 12/31/21. Pt FDODD 12/31/21. IC completed call with PT & son to discuss insurance termination. They were educated on cobra, QHP & Medicare. Second call with the son, SW & IC to discuss cobra. The son stated he is a social worker and says his father needs assistance inside the home which will be fully covered by a Medicaid Adv. The son started an application with Medicaid before the patient started at DVA.
Sub-reason (Right or Wrong)
What is Right
Patient or spouse retires or goes on LOA (more options available through employer such as COBRA or Retirement plan) but pt does not pursue cobra because of Medicare. What is Sub-reason
What is Life Event Changes
Pt has issues with 1 rounding the doctor and leaving DVA for FMC. The last tx was 4/30. IC escalated pt concerns to ROD, FA, SW, GIC on 4/10. IC reviewed DVA 5 star rating.
What is: 1. DVP 2. specify the options provided to the patient.
The patient is receiving a kidney from a relative in Florida and transferring to non-DVA for 3 treatments before the transplant.
Does this require an escalation?
What is Yes: because the patient opted for non-DVA prior to transplant
A patient that was due to start at the clinic on 3/1 never came.
What do you think? Lost to Follow up or Non-DVA Visitor
What is Non-DVA Visitor
Pt enrolled in Cobra plan and drops due to 1. OOP cost associated with coverage 2. No longer able to afford the cost of the premium and does not qualify for financial assistance
Yes (Insurance Change: cost)
Sub-reason Location: The patient is changing modality to PD so she can continue working and the facility is not near her home. The current facility does not offer PD. The patient is transferring to non-DVA to remain with MD who has PD at another of his clinics.
sub-reason right/wrong
What is wrong (transfer out, Modality)
The patient is post COB and informed by the transplant team that his deductible, copay, and out-of-pocket are extremely high. It was suggested to the patient that he pick up Medicare. His Medicare became primary. What is the sub-reason?
What is Met COB: Transplant
Pt has Aetna and is transferring to a nonDVA to get the shift he/she desires. The facility only has TTS 1 & 2, pt needs TTS 3rd starting at 3:30 pm. IC escalated the issue to field leadership. IC reached out to DVA Wyncote 1.5ml, DVA North 2ml & DVA Wissahickon 4ml
What is the pt last tx at home facility
When discharged from a 40-day hospital stay, the patient is sent to a rehab that provides on-site dialysis treatments.
What is yes: because is not returning to DVA when discharged from the hospital.
An AKI patient's FDODE is 3/17/21, and he received Medicare due to 24 months of disability. The employer has 21 - 100 employees and for disability entitlement there need to be 100 employees for COB to apply. Medicare was made primary and spouse EGHP secondary. The spouse is actively working.
what is sub-reason Patient Account or COB/Disability
What is COB/Disability