Case Study: Finance And Reimbursement

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you will learn about Hilda Smith, a woman who requires extended care and rehabilitation services due to a fall in her home. Completing this activity will help you apply what you’ve learned about financial management in a healthcare situation.

Instructions
Review Case Study #2: Finance and Reimbursement (below)
Use the template (attached) & the information from the case to answer the questions.
Case Study

Introduction
This case study follows Hilda Smith, a patient at an acute care hospital. As you watch her story unfold, think about how a case manager might incorporate a collaborative process that encompasses various areas of medical care to deliver a personal and tailored recovery plan.

Meet Hilda Smith
Hilda Smith, who had osteoporosis, sustained a hip fracture because of a fall in her home.

After 5 nights in an acute care hospital, she is admitted to an SNF where she spends 16 days for rehabilitation, nursing care, and assistance with activities of daily living. The resident is then discharged to her own home where a physical therapist from a home health agency comes in to train her to use a walker and build strength.

After being at home for 25 days, Hilda develops deep venous thrombosis (blood clot in a vein) in her thigh (related to her fall) and is admitted to the hospital, from where she is transferred to the same SNF after spending 2 nights in the hospital.

Conclusion
Write your answers in well-developed sentences or short paragraphs, using your own words.

As the case manager, how would you respond to the following questions?

Assuming that Hilda meets Medicare criteria for the services described here, how many days of SNF care is she entitled to during her most recent stay (assume that she qualifies for the full 100 days)?
How much in deductibles and copayments does Hilda have to pay? (For 2021, the Part A deductible was $1,484 and the daily copayment for SNF was $185.50.)

Sample Solution

Responses as the Case Manager:

1. Days of SNF Care:

Unfortunately, based on the information provided, we cannot definitively determine how many days of SNF care Hilda is entitled to during her most recent stay, even if she qualifies for the full 100 days under Medicare. Here’s why:

  • Medicare Part A covers a maximum of 100 days of SNF care per benefit period, but there are specific requirements for coverage:
    • The SNF stay must follow a hospital stay of at least 3 days for a related medical condition.
    • The SNF stay must be medically necessary and skilled nursing care must be required.
  • We don’t know if Hilda already used any SNF days from this benefit period.

Therefore, we need more information to determine how many days Hilda is entitled to:

  • Has she used any SNF days from this benefit period before her recent hospitalization?
  • Does her recent hospitalization meet the criteria for a qualifying hospital stay?
  • Does her current condition require skilled nursing care?

2. Deductibles and Copayments:

Assuming Hilda meets the full criteria for Medicare coverage and hasn’t used any SNF days in this benefit period, here’s what she might owe:

  • Part A deductible: $1,484 (This is a one-time deductible per benefit period, not per hospital stay.)
  • SNF daily copayment: $185.50/day x 16 days (initial SNF stay) = $2,968

However, this is an estimate. Several factors could affect the final costs:

  • Medicare Advantage plans: If Hilda has a Medicare Advantage plan, the costs might be different.
  • Secondary insurance: If she has supplemental insurance, it might cover some or all of the deductibles and copayments.
  • Skilled vs. custodial care: Medicare only covers skilled nursing care, not custodial care (assistance with daily living activities that do not require skilled professionals). If any portion of her stay is deemed custodial, she might be responsible for the full cost.

It’s crucial for Hilda to consult with her healthcare providers and insurance carriers to obtain accurate information about her specific coverage and financial obligations.

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