Archive for November, 2008
CMW Tip of the week: Understand the difference between a Medicare appeal and a Medicare reopening
This week’s tip is provided by Deborah K. Hale, CCS.
When facing a denied claim, organizations have two options if they believe the denial is wrong: file an appeal or ask for a reopening. A reopening can be used instead of an appeal if there is a minor clerical error on the claim. The basis of a reopening is to correct the minor clerical error or omission that resulted in the initial claim denial. If there were no clerical errors, and you disagree with a Medicare decision or policy, then an appeal must be made.
If you are unsure whether the issue on your claim is based on a minor error, it’s best to file initially for a reopening. You have the right to file for an appeal if your reopening request is denied. Do not file for both a reopening and an appeal at the same time; doing so will cause your request for a reopening to be considered null and void.
Valid reopening errors include:
- Mathematical or computational mistakes
- Transposed procedure or diagnostic codes
- Inaccurate data entry
- Misapplication of a fee schedule
- Computer error
- Denial of claims as duplicates, which the party believes were incorrectly identified as a duplicate
- Incorrect data items, such as provider number, use of a modifier, or date of service
Have a tip or tool you’d like to share? Or maybe a question for our experts? E-mail it to editor Julie McGinley at jmcginley@hcpro.com.Your thoughts could be featured in the next issue of Case Management Weekly!
CMW Tip of the Week: Properly document discharge plans
This week’s tip, an “Ask the Expert,” is provided by Karla Mariska, RN, a utilization review nurse at Marcus Daly Memorial Hospital in Hamilton, MT. The answer is provided by Jackie Birmingham, RN, BSN, MS, CMAC, author of Discharge Planning Guide: Tools for Compliance.
Q: What method of documentation is correct/legal on the discharge planning sheet everyone signs during discharge planning? Does entering ‘Continue medical work-up/care’ day after day really cut it, or should the notations be more specific?
A: In my non-legal opinion, the answer is NO. If the patient is in acute care, there must be some documentation of progress toward goals of the previous plan, evidence of medical necessity for continued stay, and what the next steps will be. You may want to structure the sheet that everyone signs in such a way that the basic questions are being addressed. Use the SBAR format grid: Situation, Background, Assessment, and Recommendation. Short statements in each category by everyone involved in the plan of care should meet expectations.
Example: Social worker note:
- Situation: Mrs. Jones’ discharge planned for SNF rehab.
- Background: family contacted, patient counseled about need for short-term rehab, bed available in Greenwood Nursing home for Friday.
- Assessment: discharge plans ready when patient medically cleared.
- Recommendation: contact Greenwood with update.
Have a tip or tool you’d like to share? Or maybe a question for our experts? E-mail it to editor Julie McGinley at jmcginley@hcpro.com.Your thoughts could be featured in the next issue of Case Management Weekly!
CMW Tip of the Week: Hospitalists complement case management objectives
This week’s “Ask the Expert” is provided by June Stark, RN, BSN, MEd.
Q: How can my facility’s hospitalist program help improve case management goals?
A: Hospitalists, who specialize in the management of hospitalized patients, take over for primary care providers (PCP) when it’s time to admit patients. Hospitalists work on fast-paced, intensely focused, and streamlined schedules and have been known to shave days off the average stay at a facility.
To ensure the success of your hospitalist program, take the following steps:
Assign hospitalists by unit. When hospitalists are unit-based, LOS reduction goals are easier to achieve. This is because continuity is built into a geographic-based assignment.
Establish morning hospitalist/case manager rounds. Start every day with rounds to plan the day and the stay. Daily rounds open the lines of communication and clarify the direction and goals for the day.
Expect a learning curve. Just like a new case manager, a new hospitalist will face a learning curve.
Establish guidelines promoting communication between hospitalists and PCPs. The satisfaction of the referring physician or PCP is essential to the success of your hospitalist program.
Monitor patient/family satisfaction. Survey patients and their families to determine the effectiveness of your hospitalist program and the customer satisfaction it garners.
Have a tip or tool you’d like to share? Or maybe a question for our experts? E-mail it to editor Julie McGinley at jmcginley@hcpro.com.Your thoughts could be featured in the next issue of Case Management Weekly!
