interesting learning experience in the world of authorizations

I am constantly amazed at "professionalism" in the health care field as it related to health care literacy. The current world of health care coverage requires coordination and cooperation between physicians, patients and families, providers of services and insurance companies.
Recently I have tried to engage my colleagues in the process for requesting and obtaining authorization from insurance companies for payment for the services we provide.

There are criteria for the services covered as well as restrictions on the individual plans. Also the services requested have start and end dates as well as number of visits approved
I struggle with daily reminders to field staff. I believe that part of health care literacy is the responsibility of health care providers to assist the patient in negotiating all aspects of their care- including services provided by the insurance companies.

Defining care as covered by insurances fall under 2 on-going dilemmas for professionals. One of those is the patent's right to be compliant or non-compliant. Another issue revolves around providing care that falls under the categories of necessary, needed, and nice. The grey area seems to exist now in home health care and the multitude of insurance plans. i am always told with my dealings that this call may be recorded and authorization is not a guarantee of payment.

There have been changes. To assist my co-workers I have attempted to educate and update. I have tried a 3o minute power point, a 6 minute power point, and short reminders and explanations to individual staff members as appropriate. The information has been well received, but not utilized on a day to day basis. I wonder how to address this issue.

I have been working through the thoughts of professional responsibility and accountability as the team provides care to patients. Also there is the issue that being "educated" professionals we each need to follow the processes. HUMMM....interesting thought. But it is a matter of being held accountable to assist all the elements of providing the care. It is not "just about me". Ultimately providing care requires the ability to put "all the pieces together" providing compassionate and competently appropriate care that allows the company to generate revenue and pay the bills following guidelines for services and best practices. All the time following the mission of the facility that employs us.

Dr. Rudd has done great work about negotiating the patient through the maze of healthcare. Unfortunately nursing and others have not appeared to catch up with the changes in the new professional responsibility and accountability in the climate of "services rendered". Medicare and Insurance audits as well as new restrictions on rehospitalization re-imbursement add a strange new health care literacy needed for the professional.