Navigating the Healthcare System

Focus on Patient Needs and Understanding Services

By Brittany Elko

The health care system is designed to promote patient-centered health and wellness. However, it can be very difficult to navigate. The complexity of the changing regulations, insurance coverage options and services can easily lead to frustration. Words like bundled payments, qualifying stay, and co-insurance can seem foreign to so many and when experiencing a significant illness or injury, these things can be very intimidating.

Here are some simple definitions which may also help:

  • Bundled payments – in simple terms, bundled payments compensate multiple care providers through a single -payment for all episodic treatments. This improves clinical outcomes for the patient by decreasing the duplication of services by care providers. Traditionally, Medicare pays both acute care (hospitals) and post-acute care providers (nursing homes, home health agencies, and physicians) separately for care. This approach can lead to fragmented care across multiple providers and higher cost to the Medicare program.  Under the bundle payment program, CMS (Centers for Medicare and Medicaid Services) is attempting to test an innovated payment model based on research which has shown that bundled payments can align incentives for providers – hospitals, post-acute care providers, physicians, and other practitioners – allowing them to work closely together across all specialties and settings with the goal of higher quality and more cost-efficient care.    As a consumer, you will still have a choice but will see more alliances among the different provider types developing as CMS continues to test and evolve this payment model.
  • Qualifying stay – time required, usually three (3) days admitted to acute care (hospital setting) before post-acute care is covered under a Medicare plan provided there is a need for skilled services.  A few important points to keep in mind overnight stays in the hospital when a person is not actually admitted, rather the hospital deems the stay as observation/hold,  do not count towards a qualifying stay.  Managed Care plans may have different requirements for qualifying stay. In future articles, we will be sharing information on initiatives by CMS and Medicare which can waive a three-day qualifying stay required for some post-acute services.
  • Co-insurance – The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible.

For optimal health and wellness to be achieved it is important for the patient and providers to work closely together. A critical area of conversation should center on patient needs and wishes and the availability of services. Health care is individualized to the person receiving it. What works for one patient may not work for another. It is vital to engage in conversation that promotes knowledge and understanding at all levels to ensure personalized care.

Medicare and managed care insurance companies can all have different coverage options. It is important to understand what these are in order to obtain the appropriate health care services when you need them. Coverage options can be quite intricate. If you have questions about what your Medicare or managed insurance coverage is, contact your insurance provider using the contact information listed on your insurance card or by calling Medicare at 1-800-MEDICARE or

Keep in mind that you should seek out information from trusted sources. Insurance coverage is determined by the insurance package that you elect. Many health care providers spend time working directly with insurance providers and can help to answer your questions.

The health care system is constantly evolving.  It is important to understand your health care choices and to be your own advocate in the ever-changing health care system.

For further assistance in answering your questions regarding your healthcare needs or short term rehab needs. Please contact Todd Kelleher at the Jewish Home. We will be happy to assist you in navigating the healthcare continuum. 570-344-6177 ext. 1151

Visit us:
1101 Vine St.
Scranton, PA 18510

Call us:
(570) 344-6177