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CAPC Palliative Care Discussion Forum
Billing and Finance

Next Reply: Re:Managed Care Contracting
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Post Managed Care Contracting
Author: lbogmd
Date: Aug 6, 2009 6:41 pm
We are attempting to obtain contracts with Managed Care Organizations to see (and be paid for!) their hospitalized HMO patients (we also want to see them as outpatients, but that is another, albeit related issue). We have run into several issues, which I thought I would share, to get feedback and to share our experience. First, they want to know if Palliative Care is a "covered benefit" for each plan. Then they want us to look at each plan to see if they have a per-diem or a DRG contract with the hospital. Then they want us to bill whoever benefits from the shortened LOS, either the plan, the group, or the hospital. My ultimate goal is to get a capitated contract with the medical group, but so far they have been unwilling to do any of this. Anyone with managed care stories willing to share?
Replies: order by [Date] [Author] [Subject]
Re:Managed Care Contracting (by JulieP on 08/12/2009)
Palliative Care is a specialty providing E/M services to patients needing their care. I don't think any carrier's policy specifically states that palliative care is or isn't a covered benefit. It's not classified like preventive care, screening benefits, therapy, psychiatric benefits etc.

Julie Pipke, CPC
Reimbursement Mngr, MCW
Re:Managed Care Contracting (by lhspragens on 08/27/2009)
First, I concur with Julie P.'s earlier comment. Palliative care services are part of appropriate inpatient care, not a benefit issue. It sounds like the situation may be that of a freestanding practice or hospice trying to get traction in the hospital, while the hospital is fairly unengaged. Either the palliative care provider can negotiate directly with an HMO for custom rates for inpatient or outpatient care, or the hospital contracts for services for all patients (inpatients) and possibly for custom services outpatient, that might be dependent on payer. My advice is to step back, find a strategic leader/sponsor within the hospital, and redefine the goals. We rarely see success from jumping through hoops such as those described.

Lynn Hill Spragens, MBA
Spragens & Associates, LLC

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