Archive for July, 2010
The Lean Six Sigma process applied to case management
I recently spoke with a hospital customer who was trying to improve processes in the case management and utilization review (UR) departments at a large teaching hospital. The facility recently instituted 24/7 case management in the ED and was looking to create process improvement in a culture reluctant to change.
One of my favorite quotes is attributed to Albert Einstein who said, “Insanity is doing the same thing over and over again and expecting different results.” I fear hospitals, providers, and payers are applying business-as-usual methods to a vastly changing industry. Hospitals and physicians who are willing to explore process change and embrace what other industries have used successfully will prosper.
The Lean process
According to the Lean Enterprise Institute, “The core idea in Lean Six Sigma is to maximize customer value while minimizing waste.”
Sigma is a term used to represent levels of excellence or quality. Six Sigma seeks to achieve a ratio of 3.4 defects per one million opportunities. The process began in manufacturing as a defect-reduction effort and has spread to other industries, most notably air transportation. Airlines strive to achieve perfection because lives are at stake when an error is made.
The six process elements also known as DMAIC(T) include:
- D-define opportunity
- M-measure performance
- A-analyze opportunity
- I-improve performance
- C-control performance and optionally
- T-transfer best practice (to spread learning to other areas of an organization
A company or facility that follows the Lean principles focuses its core processes on continuously increasing customer value while producing no waste. These efforts result in processes that require less input (e.g., human, space, time, or financial) which equates to fewer defects and reduced cost.
Lean makes an organization more nimble, which allows it to react to changes in the market and customer preference. A Lean organization can create products and services with more variety, higher quality, and lower cost. It can also manage information and data used to generate services more efficiently because the information is simpler and more accurate.
Key concepts
Two key concepts in the Lean method are customers and waste. To make process change you must be able to identify and quantify these concepts. I can immediately think of examples of waste in hospital processes.
Hospital errors typically occur due to the vast number of processes required to complete a task. Simple things like when a patient uses an expired insurance ID can result in case managers sending clinical information to a payer who no longer covers the individual. The time lost while sorting out the mistake can cost the hospital a day’s reimbursement.
Then I thought about the medical record. The process of several different individuals and departments documenting in the patient record is open to significant error. I can recall the frustration experienced when the chart itself disappeared.
The customer
It was a challenge to identify and quantify the case management customer.
My initial thought was clear–the patient is the customer. Then I spoke with colleagues who said the physician is a potential customer. Without physicians and other providers who admit patients and refer them to outpatient services, there would be no patient to serve. Then it occurred to me that perhaps the customer is the insurance company or third-party payer because they pay for the services consumed.
It is easy to see how many customers case managers serve. A case manager who makes arrangements for post discharge care at a SNF may say the rehabilitation facility with an available bed is the customer. The ambulance available to transport the patient to the post discharge facility is also a potential customer.
Clearly, case managers serve multiple entities. To begin successful process improvement in case management, how do we identify the customer? What are your thoughts?
Medical necessity: Don’t let documentation get away
During a recent consulting project at, I had the opportunity to observe the facility’s transition to an electronic health record (EHR).
Naturally there was apprehension throughout the facility as the countdown to “going live” approached in early June. Some of the staff nurses were concerned about learning how to navigate and chart under a totally new computer system. After all, they were comfortable charting with the current paper system.
The nurses underwent a very intensive training program in preparation for the go live date. However their documentation suffered during the first week of implementation, probably because of the learning curve that exists with a new computer system.
By the end of the first week, most nurses were beginning to appreciate the EHR’s added efficiencies and prompts. Initial apprehension transformed into general enthusiasm for the new charting system.
Case manager’s dilemma
While the nurses’ conversion to the EHR documentation module seemed to progress smoothly, there is always a chance that improving upon one area of the healthcare delivery process will impacts another key aspect of healthcare delivery. Like an automobile engine, the healthcare delivery system has countless components that depend upon each other for smooth operations. If one component fails, another component is impacted.
There is one major limitation that surfaced one week after the go live date when a case manager experienced an unexpected challenge.
A patient was admitted through the emergency department (ED) for observation services. She had relentless nausea and vomiting that began the day before she arrived at the ED. She ate fried fish at a local restaurant the night before. The physician’s initial thought was the patient had caught a mild case of food poisoning and ordered bowel rest and hydration. The patient began receiving IV fluids and IV Zofran in the ED, which continued when she moved to the floor.
After the first day of hospitalization, the physician determined that the patient was not stable for discharge. He wrote an order to convert the patient to inpatient and consulted gastrointestinal specialists. Upon further questioning the patient reported similar nausea and vomiting over the course of the last three months. The gastrointestinal specialists recommended performing an esophagogastroduodenoscopy (EGD).
The attending physician was reluctant to discharge the patient because of her continued nausea and vomiting despite the current medical management, and he elected to have the EGD performed while the patient was in the hospital. The case manager notified the patient’s insurance carrier for of the inpatient status and provided the clinical documentation. The insurance company denied the inpatient stay due to lack of medical necessity and decided to reimburse the entire stay as observation. [more]
CMS identifies common vulnerabilities, hints at medical necessity reviews
On July 12, CMS released a special edition MLN Matters article that provides education regarding vulnerabilities identified during the recovery audit contractor (RAC) demonstration. According to CMS, the information is an effort to prevent these same problems from happening in the future.
The two common vulnerabilities CMS identified during the RAC demonstration were:
- Provider non-compliance with timely submission of requested medical documentation
- Insufficient documentation that did not justify that the services billed were covered, medically necessary, or correctly coded
CMS says providers must learn from the mistakes made during the demonstration program because of “the expansion of the RAC Program and the initiation of complex medical review (coding and medical necessity) in all four RAC regions.” The language suggests that medical necessity reviews are coming soon.
Case management involvement in implementing healthcare reform
Where healthcare reform is going, is anyone’s guess at this time.
Contact your legislators and be heard!
The government powers have voted the Patient Protection and Affordable Care Act into law, but the appropriate implementation is lacking. This creates a situation where the nursing profession, especially case management, should make its voice is heard.
I know you are thinking, “right, like anyone on Capital Hill is going to listen or care what I have to say”. That is where you are wrong.
A few weeks ago, I was privileged to be a part of the American Case Management Association’s (ACMA) Advocacy on Capital Hill event. I joined other ACMA representatives in Washington DC to visit my state’s legislators, as well as other officials. It was a great experience, and we were able to voice our concerns as a powerful, organized association.
Our goal was to focus on specific areas of healthcare reform that case management can positively affect. Case managers are skilled, clinical experts in the areas of transitional care and the admit per case management protocol. Many credible healthcare organizations are developing great processes for measuring transition of care outcomes. The healthcare reform law is huge, so we focused on the areas we can speak to with expertise and authority. Nurses can greatly impact healthcare reform, as we are advocates for the patients and our healthcare organizations.
I was impressed and amazed at the differences in knowledge there was on Capital Hill regarding case management and its importance. We visited some offices where the lawmakers had little knowledge, if any, about case management, while others were well-versed in the impact of case management.
My visit to Senator Charles Grassley’s (R-IA) office is one that sticks out in my mind. I was very impressed with his knowledge of case management. He sees the importance in having case management involved in healthcare reform and the Accountable Care Organizations (ACO). I have e-mailed Senator Grassley’s office a couple of times since my trip and his staff quickly replies to my questions and concerns.
I encourage nurses and case managers to get to know their senators and representatives. Become knowledgeable of what their views are on nursing involvement in healthcare reform Contact them, and advocate for nursing participation in healthcare reform.
My experience on Capital Hill was awesome, and I learned so much. It is great to discuss these important matters and develop relationships with my senators and representatives. Don’t be afraid to be heard!
HHS will announce significant HIPAA modifications today
HHS will host a press conference to announce “significant modifications” to the HIPAA privacy and security and enforcement rules today, July 8, at 10:30 am, according to the HIPAA Update website.
It also plans to discuss “resources and activities to strengthen the privacy of health information and to help Americans understand their rights and resources available to safeguard their personal health information.”
HHS will announce proposed rules per the HITECH Act that modifies the HIPAA privacy, security and enforcement rules.
The event takes place at the HHH Auditorium, 200 Independence, SW, Washington, DC. The dial-in for the call is 800-857-6748, and the passcode is HHS.
A HIPAA question for case managers
I was discussing HIPAA with a case manager just last week, and she said her biggest HIPAA challenge comes up when she communicates with insurance companies. She said insurance companies will ask for information that she feels exceeds the minimum necessary requirement in the security rule.
However, she is in a difficult position because if she does not send the requested information the hospital will not be reimbursed.
Have you experienced this problem? Do payers sometimes ask for more patient information than you think is necessary? How do you handle those situations?
CMS update indicates high provider success rate for appealing denials
Editor’s note: This post originally appeared on HCPro’s Revenue Cycle Institute website.
A recent CMS report indicates that providers have been winning more appeals since the last update.
The June 14 report “The Medicare RAC Program: Update to the evaluation of the three-year demonstration,” updated information from CMS’ previous report, issued during January 2009 and including data inclusive through March 27, 2008. The new report, which includes statistics through March 9, 2010, reveals that the number of appeals claims dropped significantly from 118,051 reported in 2009 to 76,073 in the new data. This is because CMS no longer counts claims individually at each level of appeal. It now counts each claim once if appealed to any level.
CMS also removed claims from the appealed category if a claims contractor reversed a denial after a provider submitted additional documentation. However, because the claims contractor decides the first level of RAC appeals, it is unclear why these aren’t considered appeals, says Kimberly Anderwood Hoy JD, CPC, director of Medicare and compliance at HCPro, Inc., in Marblehead, MA. If CMS counted each of these claims as an overturned determination it would have shown that providers were even more successful in appealing denials, says Hoy.
“It would be interesting to see how much higher the overturned percentage would be if these cases were included,” she says. “Already, the stats show RACs were overturned in about two-thirds of appealed cases.”
CMS also increased the number of overall RAC determinations by 73,000 claims. The effect of including more claims in the determinations number caused the overall percentage of overturned cases to appear lower than it otherwise would have been, says Hoy.
“The new report shows a much lower number of appealed claims from 22.5% to 12.5%,” she says. “By excluding claims that were overturned by the contractor, this number shows a more favorable picture of the overall accuracy of the RAC than previous reports demonstrated.”
With the success rate of appeals so high, it may indicate that perhaps providers weren’t appealing as many cases as they should, says Donna Wilson RHIA, CCS, senior director at Compliance Concepts, Inc., in Wexford, PA.
“With the numbers reflecting 48,993 (of 76,073) cases overturned on appeal, this tells me providers should have been more proactive in appealing their overpayments,” she says. “However, healthcare providers today are extremely busy and short-staffed, so devoting numerous employee hours on appealing a RAC overpayment may not be top priority.
Given the success rate of providers who did choose to appeal, this information may prompt providers under the permanent RAC program to address their appeal efforts through alternative options, according to Wilson.
“Providers may consider hiring outside assistance in appealing RAC denials,” she says. “Seeking the opinion of a consultant will allow for expert opinions on the case and lessen the load on the existing staff.”
