To Phyllis and the others who are concernced about discharging a baby when they are not feeding effectively:

I work on the insurance side - for managed Medicaid. My title is Inpatient Care Coordinator. Just to briefly re-introduce myself: I have over 20 years experience as Registered nurse in NICU; PICU and General Pediatrics which included 10 years where I had my IBCLC before I transitioned from the direct patient care side.  I come here to help keep up my lactation knowledge base.

It is possible to have a newborn stay extended for ineffective feeding and oral intake. It is incumbent on the hospital providers to know what care guidelines are used to make authorization decisions. It is specified in the contract between the payor and facility what guidelines are used for providing authorization for inpatient admission. I am used to using one called "Milliman".  Let's go on the basis that the mother had a spontaneous vaginal delivery. The hospital will not be reimbursed for the mother's part beyond the regular stay. She will be discharged. What you are needing is reimbursement for the baby's ineffective feeding--whatever the root cause.

As a general rule, within one business day, the hospital case manager or utilization review nurse needs to notify the insurance provider that the newborn is having an extended stay and provide documentation.  Here is the big key--provide the details.  Gestational age, weight loss, details on how feeding is going. I can only provide authorization based on what clinical data is sent in to me to support the need for continued stay.  Just like any other part of the chart, if it isn't documented, it isn't done. It can't be taken into account.  I receive many requests that include very little detail. No diagnoses; no ICD-9 codes. No weights, no gestational age (very important if the baby is actually a late preterm). It's extremely useful just as here to know if the baby is down 10% or more from birth. If there isn't enough information to support the continued stay, I will send additional requests from the hospital care managment staff; however, if we don't
 receive anything further or they have waited to request the extension of stay until after the couplet has been discharged then there is very little that can be done. On the cases that aren't clearly supported by the guideline, I present the cases for medical review.  Believe me this is not a high point of my day when I have to go on and try to fight for these families when I have been sent next to nothing or an illegible scrawled mess and my requests for assistance have been ignored or worse.

It is possible to get the care reimbursed for these stays and it does happen.  It is my job and I take it very seriously. My sole focus is following the sick neonates on my contract and making sure their families have what they need while in the hospital and at discharge. However, I do have a responsibility that our limited resources are being used appropriately. We all play a part in that as well.

Sincerely,
Linda A. Madsen, RN, Inpatient Care Coordinator
Aetna Better Health - Texas
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