Level of care claims in medical billing

The level of care is defined by the amount of effort required to treat or diagnose a patient’s medical condition. Based on the condition, the health care provider detects the level of care required and ensures that appropriate care is provided. Post that, a level of care claim is filed to receive the required reimbursement. This article will talk about the different levels of care, claims, and reimbursement. 

Levels of Care

After considering the patient’s medical condition, a level of care is identified. There are different levels of care that have been categorized to treat, diagnose, or maintain a patient’s health condition. Let’s take a look at the different levels of care. 

• Acute Care 

It’s considered the most intensive level of care. Generally provided in a hospital by a variety of health care professionals, acute care is provided to patients with severe illnesses, medical conditions that occurred after a trauma or disease, and/or during recovery from surgery.

• Long Term Acute Care Hospitals (LTAC)-Long-term care hospitals (LTCHs)

Certified as acute care hospitals by the Centers for Medicare and Medicaid Services (CMS), LTCHs focus on patients who stay in the hospital for more than 25 days on average. A lot of patients in LTCHs are transferred there from an intensive care unit (ICU) also known as the critical care unit. 

Patients with more than one severe medical condition who are likely to recover with time and care get treatment in LTCHs. Some of the services LTCHs provide are respiratory therapy, head trauma treatment, comprehensive rehabilitation, and pain management.

• Sub-Acute Care/Transitional Care

This level of care is required for the patients who may not need hospital acute care but require more intensive skilled nursing care, or therapy, and/or physician services in a skilled nursing facility (SNF).

• Inpatient Rehabilitation

In this level of care, patients with functional loss are provided multidisciplinary therapy by Inpatient Rehabilitation Hospitals. Patients need to tolerate a minimum of 3 hours of therapy per day, 5 to 7 days a week, to qualify for Inpatient Rehabilitation care.

• Skilled Nursing Facility (SNF)

Under this level of care, SNF provides 24-hour skilled nursing and personal care along with rehabilitation services if required. To qualify for this level of care, patients need to be medically stable and must have a medical condition that requires a skilled, licensed medical professional. The following is an example of SNF care – Complex wound care and rehabilitation when a patient is unable to tolerate 3 hours of therapy a day would fall under this category. 

• Intermediate Care

This level of care covers the patients who need more assistance than custodial care and may require nursing supervision, which may not necessarily require skilled professionals. Most insurance companies do not cover intermediate care.

• Home Health Care

Home health care is designed to provide intermittent skilled care to patients at their homes. Home health care agencies usually cover the following services – skilled nursing, physical therapy, occupational therapy, speech therapy, and medical social worker visits. Patients who are unable to leave their homes generally qualify for this level of care.

• Hospice Care

Patients with an incurable illness fall under Hospice care. It provides end-of-life care to these patients and supports their families. For such patients to be eligible for hospice care, a doctor or physician has to document that the patient’s life expectancy is 6 months or less if the disease follows its present course of progression. Hospice care can be provided at the patient’s home, in the hospital, or a freestanding hospice facility.

• Custodial Care

Custodial care is created to support personal and home care such as Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). It does not require skilled or licensed medical professionals. Custodial care can be provided at home, in a Skilled Nursing Facility, or in an assisted living facility. Health insurance companies do not cover custodial care. 

Level of Care claims and Reimbursements 

Once the level of care is identified and reviewed, a claim is filed for appropriate reimbursement. Reviewing the level of care ensures that hospitals and other health care centers are utilizing correct billing practices. This allows the insurance companies to make correct reimbursements.