In the world of managed care, when an individualized health plan gives a managed care company the go-ahead to admit with no authorization, or what some call a “Gold Card,” the overall notion is it is a win-win for all parties involved, especially the patient. But the “No-Auth” way of doing business is not a new idea of taking a patient’s case into home care, whereby the home care agency fully manages the case from beginning to end. While this case management methodology is gaining popularity during the COVID-19 era, it seems to be only a temporary method for most health plans to conduct business. A health plan structures a case to make it work systematically to fit the needs for them as well as the home care agency and the patient. That managed care plan can do things where it’s a win-win situation for all parties, but this individualized strategy is almost never a “one size fits all” scenario.
For example, a home care agency (Certified Home Health Agency or CHHA) can eliminate the need to call the health plan asking, “if they can accept a specific case?” which is an administrative and financial burden to both the health plan and the home care agency. The provider will manage the case without authorization, providing services the health plan would have authorized anyways, but this way, it is with no administrative burden. The notion of the provider asking for, “can we take this case?”, this is an administrative step that should be deleted. The end result is that the provider would fully manage a patient’s case with the same outcomes, just eliminating the authorization process of delaying care and keeping the patient/member out of the hospital.
If a patient with a wound needs a certain number of visits, such as three visits per week for the next three weeks, the responsibility of the CHHA is to fully manage the patient’s care. What could understandably happen is that the health plan can come back at the end of the patient case and say that they reviewed the case and it was decided that the patient did not need visits or homecare; they can then deny the “No-Auth” and the health plan and provider would review the case to determine if it was medically necessary.