Home Health & Home DME

Recovery and healing where patients want to be – at home.

The Challenge

Each stage of post-acute care is interconnected. Reducing costs in one area, without careful planning, can have unanticipated impact in another area. Reducing over-utilization of Skilled Nursing Facilities (SNFs), for example, must be augmented by carefully managed home care to result in lower readmissions. Many patients also require home health or DME in the course of ongoing treatment.

Connecting the silos that exist on a patient’s post-acute care journey requires an approach that integrates home health and home DME. Unfortunately, many plans don’t have the resources or ability to affect this approach.

man playing boardgames
  • Home Health expenditures are expected to grow to $157B by 20221

  • Demand for home DME is estimated to reach $43B by 20192

  • Waste and abuse is growing in these categories as well – estimated at $1.5B – $5B each year3

What is Home Health and DME?

After patients undergo treatment, surgical or otherwise, they will be discharged for post-acute care. This care may occur at a facility, such as a skilled nursing facility or long-term acute care facility, but, in many cases, it can be administered in the patient’s home instead. The goal of home health with home DME is to give patients access to trained professionals and resources they need to heal.

The CareCentrix Approach

CareCentrix provides scalable solutions for cost-effective, patient-centered Home Health & Home DME through a national provider network of over 8,000 locations.  Our program:

  • Uses a “home first when possible” methodology, supporting patients with the services they need to heal, and reducing risks attributed to institutional settings
  • Includes approximately 8,000 credentialed provider locations
  • Offers DME, home health services, home infusion nursing, and orthotics/prosthetics/supplies
  • Provides URAC- and NCQA-accredited utilization management and support through highly trained nurses and clinical teams
  • Reduces the risks and costs of fraud, waste, and abuse
  • Calls patients 24 hours after care was expected to start, validating that they receive the care they need
nurse with elderly patient

Benefits

  • Expertise and experience

    • Coordinated more than one million home health visits in 2016, and more than 4 million orders for home DME
  • On-time care

    • Start-of-care date is met more than 99% of the time
  • Care coordination

    • Patients leaving the hospital typically need between 3 to 4 services, often supported by different providers. We coordinate services and eliminate silos between these providers.
  • Reduces fraud, waste, and abuse

    • Estimates indicate up to 10% of current health plan spend may be detected as fraud, waste, or abuse

Questions About The Home Health & Home DME Program

  • Answer: CareCentrix maintains a broad network of over 8,000 credentialed provider locations arranging home care services nationwide for our clients’ members. As new clients are added, we customize our network to best meet our clients’ needs.

  • Answer: CareCentrix has generated net savings of 12-20% on average for our DME clients. Through our national scale and unparalleled knowledge of post-acute care, we can identify savings opportunities for our clients.

  • Answer: While a relatively small percentage of members need DME, for those that do, DME represents a significant amount of their total medical spend – approximately 25% (average $15-$25K annually for our commercial population*). By optimizing the care for those members, we can identify significant cost-savings opportunities.

     

    All figures based on CareCentrix Analysis, Jan. 2018.

  • Answer:

    • CareCentrix is a leader in coordinating and managing home health services, durable medical equipment, home infusion nursing, respiratory therapy services, orthotics and prosthetics, and medical supplies.
    • Our 300+ on-staff clinicians are organized by centers of excellence, including home infusion, mobility, diabetes, and respiratory management service support. Clinicians coordinate care with physicians, discharge planners, health-plan case managers, and network providers.
    • CareCentrix has achieved accreditation in Utilization Management from the National Committee for Quality Assurance (NCQA) and is URAC accredited in Health Utilization Management.
    • We leverage proprietary data and monitor trends, product pipelines, and regulatory changes to evaluate and propose enhancements to our clients’ clinical management policies.
  • Answer:

    • Our goal is to help ensure that members have the equipment and services they need, when they need it. We meet the start of care date 99.5% of the time, often coordinating among different home care providers.
    • We pre-plan for vacations, weekends, and other anticipated high-volume periods to help prevent gaps in care delivery, and we have a rapid response plan to forecasted weather events to ensure adequate coverage.
    • We also perform patient outreach to patients within 24 hours after the documented start-of-care date to confirm on-time service delivery and validate service quality.

     

    All figures based on CareCentrix Analysis, Jan. 2018.

  • Answer:

    • CareCentrix maintains a robust program for minimizing Fraud, Waste, and Abuse, which encompasses detection, investigation and recovery. We specialize in audits of high-volume, small-dollar DME and home health claims.
    • We leverage proprietary algorithms to help identify patterns, statistical outliers, and billing inconsistent with nationally recognized coding standards or payer policies (such as up-coding, unbundling, cookie-cutter billing, aberrant billing, and diagnosis falsification).

Featured Resources

  • Leading Home: Using Big Data to Improve Care at Home

    CareCentrix is leading the path home through an approach that combines advanced analytics and clinical teams who interact directly with individual patients through proprietary workflow tools. We are helping our clients reduce waste, prevent unnecessary hospital readmissions, and help patients heal where they most want to be – at home.

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Sources:

  1. Centers for Medicare and Medicaid Services, Office of the Actuary.
  2. http://www.harriswilliams.com/sites/default/files/industry_reports/DME%20Industry%20Update.pdf
  3. http://www.bio-medicine.org/medicine-technology-1/NICB-Report-On-Durable-Medical-Equipment-Fraud-30000-2/