Archive for April, 2009
Denial Management – how strong is your process for concurrent denials?
We are evaluating our denial program only to assess that it was not as strong as we would like. As case management departments prepare for upcoming Recovery Audit Contractor (RAC), retro denials from health plans, and concurrent denials.
Our case management department looked at our process and it became clear that our management of our inpatients denials lacked process delineation. We began to re-assess this specific process as well as redefine our entire denial program.
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Case Management’s ability to change with the economic realities facing healthcare delivery systems
Have you noticed that the current economic issues are changing the way we are directing case management activities. It is important for us to stay attuned to how economic swings are impacting healthcare.
Case Management needs to be ready to adjust to the impact of difficult economic pressures. Currently we are seeing that the patients are seeking care later in their illness phase. Many consumers are waiting to get health care services until they are acutely sick and then they are seeking the most economical place to receive care. They are avoiding the costly emergency rooms, using urgent cares, or clinics.
There are many other subtle differences that rise to our concern. Some of these include:
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1. Delayed pre natal care
- a. more patients without coverage will have difficulty obtaining medications,
b. compliance with follow up appointments due to co-pays may be skipped
2. Declining inpatient volumes due to
a. Decreased elective procedures (bariatric, orthopedic, etc.)
3. Decreasing visit numbers in ED
4. Late access to healthcare
5. Increasing need to ensure there is a secure discharge plan and follow up assessment due to:
6. Increase number of social services requests from healthcare team due to more family hardships and desperate times.
7. Increase number of Medicaid applications.
Our focus is more on securing the volume and as always – providing superior service so consumers return. What are you seeing as new trends?
In the wake of the RAC, don’t forget about Present on Admission (POA)
I’m sure everyone is aware of the Hospital-Acquired Conditions (HAC) the Centers for Medicare & Medicaid Services (CMS) announced would not be paid for beginning October 1, 2008. The 10 categories of HACs are:
- (1) Foreign objects retained after surgery
(2) Air embolism
(3) Blood incompatibility
(4) Stage III & IV pressure ulcers
(5) Falls & trauma
(6) Manifestations of poor glycemic control
(7) Catheter-associated urinary tract infections
(8) Vascular catheter-associated infection
(9) Surgical site infection following: Coronary Artery Bypass Graft (CABG)—Mediastinitis, Bariatric surgery, and some orthopedic surgeries
(10) Deep vein thrombosis (DVT)/Pulmonary embolism (PE) following some ortho procedures.
When looking through this list of conditions, as healthcare professionals we realize there are steps that can take place to reduce and/or eliminate the possibility of these conditions, and then there are conditions that no matter what we do may unfortunately happen.
Condition Code 44 question
The following question comes from Debbie Love, RN, a Case Management Weekly reader.
Question regarding Condition Code 44:
Are you aware of anyone who already has a “Condition Code 44 form” prepared/template which outlines the requirements and signatures, and, once signed, would be provided to the patient?
We are considering either a patient instruction handout on what observation means that would be provided to the patient along with a signed document by UR MD, patient’s PMD, and another member of our UR Committee (such as our director of case management) or a combined “Condition Code 44 form” which includes a brief explanation of observation and its financial implications for the patient (along with all the signatures.)
We do not have a UR Case Manager in our ED, and are finding this difficult to explain once a patient has already been admitted to a bed on a clinical unit. Is there anyone else having this same issue, and if so, how are you handling this?
Thank you,
Debbie Love, RN
Compliance and Training, Project Specialist
Sibley Hospital
dlove@sibley.org
Optimizing patient flow to protect against the RAC
Waits, delays, and cancellations are so common in healthcare that patients and providers have come to expect waiting as part of the care process. But poor patient flow can have seriously adverse effects on patient outcomes and your facility’s bottom line—and can even increase your susceptibility to RAC audits.
According to Kelly Cooke, MSN, RN, the director of clinical resource management, social work, and documentation improvement at the Hospital of the University of Pennsylvania, part of maintaining optimal patient flow is placing patients in appropriate level of care and creating a system that guards against readmissions.
“If you can initially place your patients in the appropriate level of care, this will enable your facility to have a very successful RAC audit,” says Cooke. In addition to up-front processes, she recommends creating strategies to prevent unnecessary readmission.
In the April 27th HCPro audioconference, Optimize Patient Flow Through Case Management: Maintain Revenue Integrity and Joint Commission Compliance, Cooke, along with patient flow experts Derenda S. Pete, RN, MBA, and Brooke Wollenberg McDonnell, MBA will discuss how Hospital of the University of Pennsylvania created 25 virtual beds and have created a system that not only keeps them RAC ready, but has allowed them to gain, on average, four hours on each discharge. The audioconference will also offer strategies for dealing with inappropriate admits, information on how to manage the uninsured and underinsured, tips on how to collect, analyze, and distill data to improve outcomes, and suggestions on how to communicate with physicians on appropriate admission criteria.
Observation with condition code 44 and physician supervision
By Kimberly Anderwood Hoy, director of Medicare and compliance for HCPro, Inc.
Last week the American Health Lawyers Association held their annual Institute on Medicare and Medicaid Payment Issues in Baltimore. After speaking about observation at a conference session, I had the opportunity to speak to a CMS representative informally about condition code 44 as it relates to observation and also about physician supervision in hospital outpatient departments.
I had mentioned during my presentation that I was unsure how inpatient care hours should be converted following the appropriate use of condition code 44. When the case is converted to outpatient under condition code 44, I indicated it was unclear if these hours should be converted to observation or if the observation time begins at the time the inpatient status is changed and the observation order is written. [more]
Time-saving strategies for hospital case managers!
The job of a hospital case manager is complex, to say the least. Between keeping up with regulatory changes, ensuring proper clinical documentation, planning for appropriate discharge, and making sure patients receive adequate care while your facility maintains fiscal integrity, it can be difficult to juggle all that needs to be done.
In an upcoming issue of Case Management Monthly, we’d like to feature the top ten time-saving tips for hospital case managers from you, our readers. Help your fellow hospital case management professionals beat the stress of their job and optimize their time by sharing your best time-saving strategies. Send your tips to Managing Editor Janelle Randazza; all selected entrants will be featured in the June 2009 issue of Case Management Monthly and will receive a free copy of the issue.
