What’s required for admission to Pomegranate? “It depends on the private insurance carrier. Typically we need an authorization from the insurance company for treatment and a completed information packet. The clinical team will determine whether we can render the service needed, and of course completion of admission paperwork,” says Shelly Mizelle, LPN, UR/Admissions Coordinator.
Mizelle adds, “We need to make sure there’s a bed available. If a county admits, the first thing is a referral, and then an ICCA or individual child care agreement along with the admissions packet. It will vary if an adolescent is admitted to residential or shelter care. The county pays for an adolescent’s treatment and Medicaid covers professional fees- doctor, Rx, labs etc. One of our doctors has to give the order to admit a child: Medical Director-Doctor Sathappan, Doctor Vaka, Doctor Roberts.”
“For acute hospitalization, the adolescent has to be in a crisis mode-suicidal, homicidal, self-harming, displaying psychotic behaviors, for instance. There should be approval from the insurance carrier, and the parent or guardian should accompany their child. Though we like to have a professional referral- from the emergency department, therapist, Netcare, or other crisis provider, direct admission is possible. The important thing to know is that we’ll work with referrers, insurance companies and parents to arrive at the best, most effective solution for the child’s benefit,” says Mizelle.
As a UR person, what should parents and referrers know about coverage, costs and insurance? “They should know if they’re in or out of network. There is a richer benefit in-network. Sometimes we can negotiate single case agreements for coverage as there are not that many residential adolescent facilities available. When we’re ‘in network’ that means better coverage for members, less out of pocket expense. Also a parent may wish to check their Rx benefits,” adds Shelly.
How is behavioral healthcare coverage different from medical coverage? “Sometimes behavioral care is carved out to different vendors depending on the insurance carrier. A parent may wish to review the EAP benefit on their insurance card and contact member services prior to seeking inpatient care,” she suggests.
Are there any differences because we’re dealing with adolescents? “We need to make sure there are consents and releases for the patient to get treatment, but that’s also true with adults who require power of attorney (POA) or ad litem. Regardless, it’s important to remember that each patient is unique, each situation is different. It’s done on a case by case basis for the best possible outcome,” says Mizelle.
[Photo credit: Valerie, Admissions/UR Manager, Pomegranate Health Systems. Shelly has since moved into managed care.]