In the delivery of care, reimbursement arrangements for what some call ‘room and board’ and the personal attention required by specially trained staff due to intricate patient needs are often separated in billing. Some refer to the latter as “Attendant Care” or care by “Personal Assistants.” These arguments have made it into the courtroom with providers often on the winning side, especially when juries are made to understand what is really occurring.
This separated cost of care arrangement occurs in the mental health arena, hospitalization, nursing homes that bill Medicare and other public payers and private industry that bills for benefits associated with workers comp, personal injury protection and other kinds of coverage. On the surface, from a business perspective it is not that complex.
Application: An injured or ailing party lives in a residential environment, i.e., semi-independent living with attendant support, licensed adult foster care, home for the aged, skilled nursing center, etc. The daily coordination of that environment include food, snacks, general supervision, maintenance, security, administrative oversight of care activities and care delivery personnel, medical equipment
maintenance and more. This is the room and board or the dally per diem aspect of the care.
This is only a part of what life in this residential environment involves. Now let’s move to the person-centered care part.
Then, the person or persons served require special attention due to:
1. Inability to independently ambulate
2. Specially supervised transportation
3. Behavioral unpredictability
4. A tendency toward self-harm
5. Frequent attempts at elopement
6. Special medication administration needs
7. A tendency toward sexual impropriety
8. Wound care, not separately billed
9. Intellectual inability to independently prepare meals or snacks
These costs are associated, not with the logistics of the physical domicile, but with the care needs of the individuals being served. This is typically billed hourly based upon the specifically diagnosed, observed and physician confirmed needs. There are instances when this hourly cost may be bundled into the daily per diem, but always reflected in what is billed. Accordingly, when an adjuster or other party seeks to minimize services performed or even belittle them with the uninformed accusation or designation of “double-dipping” it is easily refuted in a clinically and legally appropriate manner.
One thing for sure, Medicare is never billed by a hospital or nursing home for the cost of a bed with specialized nursing, intensely specialized personal care, physician care, radiology, dialysis, and rehabilitative therapy offered at no additional cost.
This makes the development of the comprehensive Treatment Plan a necessity for guardians and care providers. Such a plan should outline how care arrangements are organized and billed, including identifying applicable CPT codes where necessary. Costs should be itemized, and their explanation attached.
The threat of patient elopement is a regular basis for added care cost associated with supervision of residential environments. This must be accomplished without compromising fire safety, making human intervention a necessary ingredient. This adds to the cost of care.
Medical data and market reality make the term “double-dipping” potentially irrelevant. It surely is no replacement for conversation aimed at reaching mutually acceptable arrangements between the reimbursing party and care providers.