Registetred Nurse in WI with few questions.

Jun 4, 2019

  1. RNwithquestions
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    RNwithquestions New Member

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    I am a registered nurse in the state of WI that takes care of a 14 year old girl with multiple diagnoses qualifying her for private duty nursing. Her family has a primary commercial insurance plan and Medicaid as a secondary. We have to submit documentation to the commercial insurance to be paid, as they are the primary, and we are paid from them. My question is, the mother is also a RN who was approved as a caregiver on the case. We bill a certain amount, and they pay us 50% reimbursement. It is determined based off of 140% of the Medicare rate, however there is no Medicare rate, so we are reimbursed 50% at any amount we bill. The mother submitted documentation to take care and bill for her child, and she bills for whenever nurses are not there (several hours weekly - including when he is asleep). He is approved for 24 hours of care per day through insurance. Based off of her documentation, she is making around $35,000 a month to care for her him. I know the obvious ethical issues, however should I be concerned as a caregiver working on this case? It does not seem right that a mother should be reimbursed to care for their own child, special needs or not, especially not to the tune of hundreds of dollars per hour to be in their own home. Thank you for any advice anyone may have. Feel free to ask any questions if they arise.
     
  2. somarco
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    somarco GA Medicare Expert

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    Since this appears to be a claim issue, it is up to the carrier to decide to honor the bill from the mother or not.

    Whether this seems "right" to you or not, really isn't your concern.

    You stated the the mother was an RN. She is submitting bills. She is being paid.

    As I see it, this is no different from having another nurse from a different provider working their shift and you working yours.
     
    somarco, Jun 4, 2019
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  3. LostDollar
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    LostDollar Guru

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    (Caveat, not an insurance agent.)

    I agree with somarco 100% on this issue.
     
  4. DI Guy
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    DI Guy Expert

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    Generally speaking, insurance claims departments don't actually want to write checks. They have a responsibility to their shareholders, employers, agents, and clients to make sure that only valid claims and bills get paid.

    Keeping that in mind, if the carrier is cutting a check then they feel it's in the best interest of their company. This goes both for fulfilling their policy contract and serving their client.

    In this specific case, the mother doesn't seem to be getting paid to be a mother, she's getting paid because she has a very particular set of skills. Skills she has acquired over her career.

    Also, since the carrier is paying her, what are the 'obvious' ethical concerns. I am curious because it seems the carrier has not noticed them.
     
    DI Guy, Jun 6, 2019
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  5. fed up
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    fed up Guru

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    From 2010 until late 2012 I cared for my invalid father in law while the live in care giver was "off". I WAS permitted to submit bills for my time and charge for overtime during the night care. I did not take a dime from anyone but I could have and the years that have taken a toll on my health will never be recovered. If you have an ethical question about how this person is billing or getting paid, find another family to care for. I can tell you that I did not get more than 4 hours sleep for over 3 years. I have also been charged $10 for a tylenol in a hospital. Turn your anger towards your own profession
     
    fed up, Jun 6, 2019
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  6. DI Guy
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    DI Guy Expert

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    @fed up: Good point. I was focusing on the RN part, but yeah I was paid for a couple of years while taking care of my mother. It was a more than full-time job and the income kept the roof over us while I did what I could when the skilled person was not there. Exhausting.
     
    DI Guy, Jun 6, 2019
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  7. LostDollar
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    LostDollar Guru

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    Sounds like a bargain to me! i may have to ask you for a hospital reference next time I need one. :laugh:
     
  8. LostDollar
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    LostDollar Guru

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    I am glad to see the posts about the emotional strain involved for family members even if they have certifications that meet the insurance company's requirements for payments under a policy.

    Even for nurses that care a lot, I think there is a difference working an 8-12 hour shift at a hospital (or likely even private home or hospice) and caring for an ill parent, spouse or child.
     
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