RSSArchive for March, 2010

RACs continue to add DRGs to target lists

I don’t know about you, but I am worried about the ever growing number of DRGs added to the Recovery Audit Contractors’ (RACs) target lists.

One RAC plans to audit more than 75% of all DRGs that hospitals in their jurisdictions submit. Initially I was puzzled. Why so many issues with the DRGs? The coders do a good job. They use software. What is the problem?

Yesterday, the proverbial light bulb went on for me. It’s not the coders fault. I would like to share the anecdote that got me thinking.

In the late 1990s, a health plan quality improvement nurse colleague asked me to help design a disease management program with a major pharmaceutical company. The intent of the program was to improve outcomes for their many diabetic and congestive heart failure (CHF) members.

We needed to identify about 500 potential candidates for the program. My colleague had her IT folks identify 1,000 members whose claims included diagnoses for diabetes and/or CHF. We pulled 1,000 charts knowing that some would not meet criteria, but we were confident we would find more eligible patients than we needed.

We reviewed 1,000 outpatient clinical records to determine each patient’s eligibility for the program. Those of us who reviewed the records audited the provider’s outpatient record against a clinical data set provided by my quality improvement colleague. The idea was to validate the diagnosis on the claim against the patient’s actual condition. No big deal. I thought.

To substantiate systolic CHF we looked for an ejection fraction below 50, weight fluctuations, positive chest x-ray, use of diuretics, etc. For diabetics were looked at the HBA1C values, medications, presence or absence of complications, etc.

I was surprised that two-thirds of the CHF charts we reviewed did not contain documentation to support the diagnosis when compared to clinical criteria. In fact, many CHF patients had ejection fractions well above normal. We were barely able to identify 300 cases with clinical documentation and lab/radiology results that supported the coded diagnosis.  In my opinion, the coders were not at fault because they worked with the diagnoses recorded in the chart.

Diabetes was not as problematic, but we did see many errors in diagnosis assignment based on lab results and lack of documented complications.

The case management and utilization review team I worked with focused on commercial admissions because we were short-handed. Commercial payers typically require clinical review within 24 hours of admission or else they will deny the day.

We knew CMS would reimburse something for the Medicare admission because of the DRG payment system. Since there was no need to call in clinical information for Medicare patients (unless they were managed Medicare) most Medicare admissions were overlooked until discharge planning. Not ideal, but we did the best we could.

Do you think the RAC auditors are discovering the same or similar issues with DRG assignment? How many case managers are actively working Medicare admissions?

What problems do you think the RACs are finding with the DRG assignment that are causing the scrutiny now?

March 30, 2010 | | Comments 2
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Providing patient choice for post-acute care

The patient’s right to choose is one of the most basic patient rights. When it comes to discharge planning, Medicare rules require hospitals to involve the patient in the process. They also must give patients a choice between the available and appropriate post-acute services (e.g., home health agencies and skilled nursing facilities).

According to the Conditions of Participation for Hospitals in Section 482.43:

(7) The hospital, as part of the discharge planning process, must inform the patient or the patient’s family of their freedom to choose among participating Medicare providers of posthospital care services and must, when possible, respect patient and family preferences when they are expressed.

The concept seems straightforward, but many readers have recently been asking for additional clarification on the following issues:

  • Documenting that the hospital provided post-acute discharge options to the patient
  • Whether to include options that are off-plan
  • Whether it is necessary to give choices to patients that are admitted from a nursing home they are satisfied with
  • Whether it is appropriate to advise a patient on which facility to choose
  • How many options the hospital should provide

Jackie Birmingham, RN, MS, vice president of Curaspan Health Group and author of HCPro’s Discharge Planning Guide,  answered two reader-submitted questions for the Case Management Weekly e-newsletter on the topic. The following are Birmingham’s responses:

March 25, 2010 | | Comments 0
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Proactive discharge planning and collaboration with community resources leads to discharge without readmission

With so much going on in healthcare today, it is difficult to sift through the complexity and know what to do and when. Healthcare professionals keep hearing about proactive discharge planning, collaboration of care, transition to home, and preventing readmissions, but do we know how to put all these ideas together in the right sequence to improve quality of care?

Improved patient care starts with relationships. Hospital case managers and social workers must work with community home healthcare agencies, nursing and skilled nursing facilities, and the insurance company utilization management resources. Let’s see how strong relationships help MaryJo (MJ) as she makes her way through an inpatient hospital stay.

Educating MJ

MJ is a 59-year-old female who works as an administrative secretary. She is married and has two grown children. MJ has insurance through her employer and has been in the hospital three times in the past seven months for recurrent exacerbation of her COPD.  During this admission, MJ ’s case manager immediately begins to discuss discharge planning with MJ and at interdisciplinary rounds.

At the interdisciplinary rounds meeting, staff notes that MJ has never participated in pulmonary rehab. The case manager also speaks with MJ’s insurance company and discovers she does have benefits for pulmonary rehab and home healthcare services. The social worker works with the area home healthcare agencies and finds one with a well established COPD disease management program. MJ is tired of being in the hospital and agrees to participate in the program.

The primary nurse speaks with MJ and discovers that no one has explained how MJ’s prescribed treatment will help her. MJ admits that others have taught her the anatomy and physiology of her disease, but no one has told her why she must follow through with her treatments and what she can do to control her COPD.

[more]

March 22, 2010 | | Comments 1
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Medical necessity—It’s a physician thing

Medical necessity for inpatient hospitalizations—or lack thereof—is a contentious topic that case managers face on a daily basis. The patient’s clinical presentation to the ED, severity of illness, physician assessment, or proposed plan of care does not always establish medical necessity.

When the patient meets the parameters of medical necessity at admission, he or she often reaches medical stabilization, thus meeting criteria for safe discharge. However, physician resistance can sometimes stand in the way of an appropriate discharge. Physicians may wish to watch the patient an additional day or may acquiesce to a patient’s desire to stay one more day.

Competing forces

While case managers and physicians have long battled over adherence to reasonable standards of medical necessity, several factors have made promoting efficient use of hospital resources through physician education all the more important:

  • Dwindling third party-payer reimbursement
  • More aggressive insurance company nurse reviewers
  • Increasing numbers of uninsured or underinsured patients presenting to the hospital

However, competing financial incentives make it challenging for case managers to instruct physicians to adhere to medical necessity standards and use resources efficiently.

Physicians receive payment for their evaluation and management (E/M) services, while placing providers at financial risk through the admission and continued stay process, regardless of medical necessity. Physicians account for up to 20% of the healthcare dollar expenditures through face-to-face patient encounters. They also account for up to 90% of dollar expenditures through orders for services such as home health, physical therapy, and radiology and laboratory tests. [more]

March 08, 2010 | | Comments 3
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ACMA takes second Important Message from Medicare concerns to CMS

The American Case Management Association (ACMA) CEO Greg Cunningham recently met with CMS officials to discuss the results of the ACMA Public Policy Committee’s survey about the second Important Message from Medicare (IM).

According the ACMA, CMS was “receptive to the feedback.” The results of the survey include the following:

  • The majority of respondents (84%) report that case management is responsible for issuing the second IM
  • More than half the respondents (59%) report that 10 minutes or less are required to issue each IM
  • More than 77% of respondents report that they track IM compliance
    • Of those who track IM compliance 40% report a compliance rate between 76% and 100%
  • Only 38% of respondents report increased numbers of appeals
  • The majority report that less than 25% of patient appeals are successful
  • Respondents generally feel the second IM process adds little value to patient care and adds to patient confusion and frustration

Read the full CMS Important Message / Appeal Rights Notification Requirement Survey Findings report.

CMS officials asked the association to gather a prioritized list of the most pressing concerns about the delivery of the second IM. The ACMA and CMS will then work together to address the 10 most pressing issues.

If you would like to contribute your thoughts on the second IM you have two options:

March 05, 2010 | | Comments 5
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