Wisconsin LTC Struggles 2 Address Claims Reimbursement Cycle Deficiency

Wisconsin long term care is examining the role of the claims reimbursement cycle in relation to diminished (less than adequate) provision.   Cycle liquidity is making sure contracted claims generators get reimbursed rapidly. 

The claims and reimbursement cycle influences participation.  The function of a delivery network is dependent upon participation to produce savings. 

This looks at a supportive care provision:

    TYPE                             RATE                    UNIT

Supportive care              5.00                      15 minutes       

The supportive care provider is reimbursed 5 dollars for every 15 minutes of service.   This is the fixed elements of the process.   The health administrator authorizes the service type and number of units and the supportive care provider performs the service before the claims- reimbursement cycle begins.

Administrator communicates the service type and number of allowed units to the payer.   The supportive care provider communicates the service type and number of performed units to the payer. 

The only variable on the authorization- provision side is the name of the beneficiary and number of units per day.  The rest of the communicated information is fixed- static. 

The Payer (third party billing) has out sourced the claims reimbursement process to out of State locations.  This is correlated with excess unpaid claims (over hang) and inefficient reimbursement. 

  Excess unpaid claims and inefficient reimbursement exerts downward pressure on participation.  This dynamic is clearly documented within the operating Wisconsin long term care delivery today.   Large numbers of long term care beneficiaries have been authorized for service in the absence of contracted providers. 

The family will say we are eligible for many hours of care but cannot find a provider contracted with the public program we have selected.   The family is without help.  The inability of the family to find help is directly related to the claims- reimbursement cycle.

According to a supportive care industry group the number one reason for not contracting with public programs is inefficiencies within the claims reimbursement cycle. 

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