Author Archive for Ben Amirault

2009 Case Management Monthly salary survey

We need your help.

We at HCPro want to provide you with the salary information for case managers that you need in the most useful format.

Please help us better understand your position by completing the 2009 Case Management Monthly Salary Survey. The survey results will be included in an upcoming issue of Case Management Monthly.

The link below will take you to the survey’s Web site; simply click on the link to answer the survey questions online. If the click-through does not work, please cut and paste the URL into the address bar of your browser. Here’s the link to the survey:
http://www.zoomerang.com/Survey/?p=WEB229QJRN9FKN

Thank you for your time and assistance.

The ZPICs have begun in zone 4

Health Integrity LLC, the zone four (Colorado, New Mexico, Oklahoma, and Texas) Zone Program Integrity Contractor (ZPIC), has begun requesting medical records for review.

The ZPICs are Medicare audit contractors that specifically identify cases of fraud and abuse. According to the CMS Program Integrity Manual, ZPICs may “take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped.”

During HCPro’s November 3 audio conference, “Zone Program Integrity Contractors Learn Who They Are, What They Want, and How to Respond to a Review”, a caller from Oklahoma shared that a Health Integrity representative visited the facility recently and stayed for a two-day, on-site audit. During the visit, the auditor reviewed more than 40 medical records related to one-day stays dating back as far as 2007.

This information came as a mild surprise to Robert Wade, partner at Baker and Daniels, LLP, in South Bend, IN. Wade said ZPICs have the authority to start reviews as soon as they are awarded the contract, and Health Integrity was awarded the zone four contract in February.

Facilities should be aware that ZPICs could notify the facility via fax a mere hour before the visit. This can leave little time for the facility to prepare. Wade said in situations where ZPICs give short notice, facilities are within their rights to supplement any requested records with supporting documentation even after the visit is complete.

So far CMS has awarded only three of the seven ZPIC contracts:

• Zone 4: Colorado, New Mexico, Oklahoma, and Texas—Health Integrity LLC
• Zone 5: Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia—Advance Med
• Zone 7: Florida, Puerto Rico, and Virgin Islands—SafeGuard Services LLC

So what does this information mean for providers that are within one of these zones?

“They can come knocking at any time,” Wade said.

Consequences of a ZPIC review include payment denials, recoupment of overpayments, and referral to other law enforcement agencies. Because ZPICs can refer cases to the Department of Justice, Office of Inspector General, or other law enforcement agencies, a ZPIC review may only be the first step in a long legal battle.

Have you heard about the ZPICs starting in any other zones?

Possible MIC audit issues that involve case management

Editor’s Note: This post was excerpted an article on the Revenue Cycle Institute Web site.

There’s no question that audit activity is escalating.

It’s no longer just RAC, MAC, CERT, and ZPIC audits looking to ensure the accuracy of Medicare payments. Providers are also subject to increased scrutiny on the Medicaid side, as states are working with the federal government to help reduce payment error rates and recoup overpayments.

The scrutiny comes in the form of Medicaid Integrity Contractors (MICs), who will begin auditing providers in all states by the end of 2009.

What will MICs be auditing? It will vary from state to state, of course. But James G. Sheehan, the Medicaid Inspector General for New York, listed several issues he expects the MICs will audit during the October 15 HCPro audio conference, “Medicaid Integrity Contractor Audits: Know What to Expect and How to Prepare.”

The following are some of the potential MIC audit issues Sheehan listed that case management staff members should be aware of:

• Heart failure and shock. For this issue, MICs will look for failure to meet InterQual criteria for inpatient care.
• Ambulatory surgery with no complications to justify inpatient stay. “Commonwealth Fund just came out with a ranking of the states on this issue, and some states are better than others. It may not be a bad idea to find out where your state stands and whether this will be an issue,” Sheehan says.
• Observation beds. This is always a popular issue because Medicaid rules differ by state and also differ from Medicare in most states, explains Sheehan.

Editor’s note: Sheehan and Sarah Kay Wheeler, partner at King & Spaulding LLP in Atlanta spoke during the October 15 HCPro audio conference, “Medicaid Integrity Contractor Audits: Know What to Expect and How to Prepare.”

For additional background information view the April 22, 2009 GAO report “Improper Payments: Progress Made but Challenges Remain in Estimating and Reducing Improper Payments,” visit the GAO Web site.

Listen to expert interpretation of Condition Code 44 regulations

Condition code 44 is one of those topics that never goes away.

• Can we use condition code 44 if the physician has already written the discharge order?
• Can we use condition code 44 if the attending physician doesn’t concur with the utilization review committee?
• Can we use condition code 44 to change inpatient time to observation services?

For whatever reason questions like these continue to come up. Perhaps it’s the vaguely-worded regulation or the conflicting advice found on the internet. Whatever it is, people are confused.

We at HCPro were thinking that because condition code 44 is such a contentious and confusing topic perhaps a written article is not the best way to explain it. That’s why we decided to call in the experts (Kimberly Anderwood Hoy, JD, CPC, the director of Medicare and compliance for HCPro, Inc and Sandra McCune BSN, RN utilization management specialist) for a 90-minute audioconference that will hopefully put all your condition code 44 concerns to bed.

How and McCune will share their interpretation of the rule using the official guidance provided by CMS. The program includes a 30-minute question and answer portion that will give you the chance to get your burning condition code 44 question addressed by our experts.

Take a listen to the following audio clip I recorded with Kimberly Hoy. In it, she explains why it is important for folks to listen to the program and highlights some of the important information the audience will take away.

If you like what you hear head over to the HCMarketplace and sign up for the program, Condition Code 44 and the Utilization Review Committee: Ensure Process and Documentation Compliance.

Is H1N1 hype clogging your ED?

Is it a cold or something worse?

The nightly news is teaming with stories about seemingly healthy young people becoming critically ill from the H1N1 virus, and people are worried.

I am no exception. When I hear a coworker cough of sniffle, I get a little uneasy. I have been able to stay healthy during this young flu season. However, should I find myself running a fever and coughing, my unease might turn to worry. And where do most folks go when they are worried about their health? The doctor, or if they can’t wait for an appointment, the ED.

EDs are crowded as is. The last thing ED staff members need is people presenting to the ED that are afraid their head cold could kill them. That is why Emory University and Microsoft have teamed up to create a the H1N1 (Swine Flu) Response Center.

The H1N1 (Swine Flu) Response Center is a Web-based assessment tool that asks site visitors a series of questions, including:

• Age
• Gender
• Geographic location
• Severity of symptoms
• Length of symptoms

After answering these questions, users receive symptom management advice. In severe cases, the tool instructs users to consult a physician immediately. In less severe scenarios, the tool may instruct users to visit a walk-in clinic or stay in bed and drink fluids.

Site sponsors hope people with less severe symptoms will use this tool’s advice instead of visiting the ED, but is it enough? Some folks might be satisfied by this tool opinion, but others might not trust the advice, after all, there is no better cure for worry than the clinical judgment of a real, live healthcare professional, right.

Tell us about what is going on at your facility. Is your ED crowed with people with flu symptoms, looking for a little reassurance that they are not facing peril? Has your facility developed a system to handle the expected surge in visitors?

Speak up: CMSA urges case managers to contact local legislators

You may have heard, but Congress is attempting to enact some type of healthcare reform in the near future. Although the extent of that reform is still up for debate, the conversation about how to improve the current healthcare model is not going away.

What better way to celebrate National Case Management Week than to contact your local legislator and tell him or her about how case managers can improve the healthcare system?

Healthcare reform will have a huge impact on the way you do your job, which is why The CSMA Public Policy Committee is encouraging case managers to speak up and share their experiences.

“We want case managers to share their stories with their local legislators,” said Carol A. Gleason, MM, RN, CRRN, CCM, LRC, BCPC Chair of the CMSA Public Policy Committee.

Gleason says she and the committee are not asking people to talk politics, but rather share what works with the current model and what needs improvement. The idea is that if case managers and other healthcare professionals share their wealth of knowledge with lawmakers, who have likely never worked in a hospital, than our government will be better equipped to create reform that works.

You can also think of it as another form of patient advocacy. Case mangers know how the system affects certain populations because they deal with difficult case everyday. This is a chance to tell the story about the time it broke your heart to tell someone, “I’m sorry but that’s just how the system works.”

The Case Management Model Act

The public policy committee has also created a Case Management Model Act which defines the case management role and explains how the case management principles can be the building blocks for successful healthcare reform. You can download a copy of the Model Act at the CSMA Web site. While you are there, check out the sample letter you can send to your representative and the list of talking points you can use to call him or her directly.

Case Management Week is almost upon us

Case managers, next week is all about you. October 11-17, is National Case Management Week, which is your opportunity to spread awareness about what case managers do and how they improve healthcare across the continuum of care.

Several case management associations have released information that describes how you and your staff members can celebrate all things case management.

If you are looking for National Case Management Week posters, banners, and pins check out the American Case Management Association’s National Case Management Week catalog.

The Case Management Society of America (CMSA) put out a 20-page packet that is full of ways you can raise case management awareness:

• Individual activities
  • Tell 10 other professionals you are a case manager.
  • Offer to speak at community events on case management.
  • Write letters to your local paper. Contact radio and TV stations to let them know about CM Week.
  • Write a guest editorial to newspapers, journals or magazines regarding the positive impact of case management.
  • Distribute a press release announcing National CM Week.
• Community activities
  • Host a celebration or reception to recognize a case manager in your community.
  • Host professional seminars and workshops for health professionals in your community.
  • Arrange exhibits and displays in public facilities.

This is not an exhaustive list. See the full list of suggestions at the CMSA Web site

Please share your plans for National Case Management Week.

Lessons learned at the Case Management Administrator Intensive Workshop

This week I took the opportunity to learn more about the case management profession and get a sense of what issues case management administrators are struggling with. I spent Monday and Tuesday of this week attending The Center for Case Management’s Case Management Administrator Intensive Workshop in Boston. It was two info-packed days and at the end I emerged from the convention center with enough story ideas to get me through to next spring.

Here are a few quick nuggets of wisdom I took from the workshop:

• The group at the workshop represented a great cross section of the national case management scene, which made for a well-rounded discussion. There were representatives from small non-profit facilities and large hospital systems. Some flew in from the west coast, others drove up the east coast, and one case manager even made the trek from Taiwan.

• The attendees had a laundry list of issues they struggle with everyday including:
  • Creating data dashboards
  • Recruiting and retaining staff in a tough economy
  • Structuring transfer agreements
  • Creating a utilization review committee
  • Using condition code 44
  • Defining case management and social worker roles

• Karen Zander RN, MS, CMAC, FAAN, principal and co-owner of the Center for Case Management had a great simile for case managers. She called them the immune system of the hospital. Much like the immune system, case managers typically keep all the hospital’s functions working properly while going relatively unnoticed. However, when the hospital gets sick (e.g. denials increase, patient satisfaction goes down, readmissions go up, etc.) they quickly come to the forefront.

• Tina Davis, RN, MS, CNS, CMAC, said “The RAC solution is in case management.” What she meant is that a strong case management program can prevent many of the issues RACs commonly search for including medical necessity, level of care, condition code 44, proper MS-DRGs, and readmissions.

• Kathleen Bower, DNSc, RN, FAAN co-owner of the Center for Case Management urged the attendees to make case management a data driven department. Data supports what the case management department does for the hospital’s bottom line. With data, case management administrators can negotiate more resources for the department, assess new policies and practices, and demonstrate the value of the department.

• Bonnie Geld, MSW, advised that case managers should not limit their knowledge of a case to what is on the record. Geld said case managers should “go see, touch, smell, and speak to the patient.” Taking the time to interact with a patient early and often can help develop a discharge plan that takes into account the patient’s family, economic, and mental status.

One year later: How are you handling HAC and POA

Last October, CMS began paying hospitals less for certain hospital-acquired conditions (HAC) that occur in specific situations and are not present on admission (POA). CMS designed the program to save money by ceasing to pay hospitals for conditions that could have been avoided. However, a new study published in the September 9 issue of Health Affairs, estimates that the program has saved $1.1 million to $2.7 million annually.

Before the HACs took effect, many experts warned that the HACs could affect the hospital’s bottom line, but this study suggests that may not be the case. Have they affected your hospital’s bottom line?

The following HAC conditions took effect October 1, 2008:

1. Foreign Object Retained After Surgery
2. Air Embolism
3. Blood Incompatibility
4. Stage III and IV Pressure Ulcers
5. Falls and Trauma

• Fractures
• Dislocations
• Intracranial Injuries
• Crushing Injuries
• Burns
• Electric Shock

6. Manifestations of Poor Glycemic Control

• Diabetic Ketoacidosis
• Nonketotic Hyperosmolar Coma
• Hypoglycemic Coma
• Secondary Diabetes with Ketoacidosis
• Secondary Diabetes with Hyperosmolarity

7. Catheter-Associated Urinary Tract Infection          (UTI)
8. Vascular Catheter-Associated Infection
9. Surgical Site Infection Following:

• Coronary Artery Bypass Graft (CABG) – Mediastinitis
• Bariatric Surgery
  • Laparoscopic Gastric Bypass
  • Gastroenterostomy
  • Laparoscopic Gastric Restrictive Surgery
• Orthopedic Procedures
  • Spine
  • Neck
  • Shoulder
  • Elbow

10. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)

• Total Knee Replacement
• Hip Replacement

If you are finding HAC and POA is an issue at your facility, check out these tips. Garri Garrison, RN, CPUR, CPC, CMC, director of consulting services at 3M Health Information Services in Atlanta, offered the following tips for keeping staff up to speed on HACs and POA in the September 2008 issue of Case Management Monthly:

• Educate case managers on what POA status is and partner with your health information management department to determine where POA codes apply.
• Be aware of new HACs when they’re announced by CMS. “This is just the beginning. It’s likely these conditions will continually evolve,” Garrison says.
• Look at your facility’s current documentation selection tools to see whether they lend themselves to capturing these data on admission. If they don’t, improve them.
• Do a self-audit. Randomly pull 30 charts to see whether they accurately note POA conditions. If you think there are gaps, chances are an auditor will as well.

“If you fail your own audit, you’re going to fail others, such as the recovery audit contractors’,” says Garrison, who describes case managers as “quality of care managers” and points to POA guidelines as “quality indicators.”

For more information on HACs, visit www.cms.hhs.gov

To listen to the HCPro, Inc., audio conference “POA Reporting for Hospital Acquired Conditions: Strategies to Obtain Complete Documentation,” visit www.hcmarketplace.com.

To read the complete article ” Don’t let HACs cut into your bottom line“, visit the ACDIS Web site’s Helpful Resources section.

One bad run-in shouldn’t define entire field of case management

Editor’s Note: I came across this letter to the editor that Nancy Sullivan, Director Case Management Massachusetts General Hospital Boston, submitted to the Boston Globe in response to an op-ed column that spoke negatively about case managers. I would like to thank Nancy Sullivan for allowing her letter to also appear on the Case Management Mentor blog.

In her op-ed “The ‘quicker and sicker’ exit strategy’’ (July 30) Deborah Schuss describes her family’s negative – and indeed, unacceptable – encounter with a case manager. One patient’s bad experience, however, should not define an entire field.

As trained and experienced nurses, social workers, and other health professionals, case managers work diligently and compassionately to ensure a safe transition for patients from the hospital to the next setting of care or home. Case managers serve as trusted guides during a period of uncertainty and change, helping families sort out details of ongoing care, and arranging for services after discharge.

As essential members of the patient care team, case managers advocate for the patient and family as they collaborate with physicians, nurses, and others. And while case managers help ensure that care is delivered in a timely and cost-effective manner, their decisions are driven by what is in the patient’s best interest.

I am privileged to witness each day the impact of case managers. One grateful patient wrote that his case manager “went out of her way to do detailed planning about my discharge, checked in with me regularly, was patient with all the questions I had, and reached out to my wife in addition to myself.’’ A family member expressed deep appreciation to a case manager who had spent extraordinary time arranging medical care in Florida so that a terminally ill young mother could travel to Walt Disney World with her children.

These are the case managers I know – true representatives of a profession I am proud to be part of.

Nancy Sullivan
Director Case management Massachusetts General Hospital Boston