CMW News: Demand for Medicaid increases while funding decreases

Since the economic recession began in December 2007, the unemployment rate has risen from 4.7 to 6.7%. Economists estimate that each 0.1% rise in the unemployment rate translates into an additional one million enrollees in Medicaid and the State Children’s Health Insurance Program (SCHIP), according to a Kaiser Family Foundation report.

This increase in enrollment comes at a time when tax revenues are falling short of predictions, leaving a large gap in funding for the programs. State governors are asking President-elect Barack Obama and Congress to increase the federal government’s share of spending by $40 billion. The governors say this would help states reduce service cuts or tax increases needed to balance state budgets.

So far, 19 states have proposed or enacted cuts to Medicaid and SCHIP for the current year or fiscal year 2010. For example, Governor Arnold Schwarzenegger (R) of California has proposed changing income eligibility for parents of SCHIP enrollees to 72% of the poverty level from the current level of 100%.

Source: San Francisco Chronicle

CMW News: Massachusetts seniors waitlisted for homecare

Because of state budget cuts in Massachusetts, many seniors find themselves on a waiting list of more than 300 names to receive the help of a homecare aid—a waiting list that didn’t exist two months ago.

Homecare aids help seniors avoid costly nursing homes by giving them assistance in their homes with basic tasks such as bathing and grocery shopping. However, state budget cuts took away about $4 million—or 3.6%—of the funding for the program.

Homecare representatives say the cuts are ironic because keeping seniors out of nursing homes saves the state money. Since the homecare program began in 2001, the number of patient days in nursing homes has decreased approximately 21%, according to The Boston Globe. The state pays about $158 per patient per day in a nursing home and only about $8.76 per day for each resident enrolled in the homecare program.

Sources: HealthLeaders Media, The Boston Globe

CMW Tip of the Week: Standardize physician level of care orders

This week’s tip is provided by Deborah K. Hale, CCS.

When it comes to discerning level of care orders, free-hand orders are not always consistent from one physician to another, making it difficult to determine the physician’s intention.

An attempt to use standardized order sets to promote clarity of the physician’s order may be problematic if the format is poorly designed or if the level of care description is unique to your hospital. Orders such as “admit to medical short stay” (an internal description representing observation status for medical patients) would not likely be recognized as an appropriate observation order by an outside auditor.

For best results, checkboxes allowing the physician to choose the intended level of care will improve the level of care order accuracy if they are easily visualized and the opportunity to select the level of care is large enough to identify the physician’s selection. Wording should be consistent with Medicare/Medicaid regulatory guidelines and admission screening criteria sets:

• Admit as inpatient
• Admit to observation status
• Outpatient status (outpatient surgery, outpatient blood transfusion, etc.)

Computerized order entry should be designed to require the physician to select the level of care before proceeding with any other orders. To avoid any confusion, the level of care choices should reflect CMS required terminology described above.

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!

Improve patient advocacy by creating a managed care partnership

Managed care companies are viewed as the Goliath to a case management program’s David. Although they may be perceived by some as the angry giant battling the defenseless healthcare facility, some organizations have found there’s a friendly way to allay an intimidating beast.

One hospital says, however, that creating a partnership with a managed care company doesn’t have to be a battle.

“ When you create a trusting partnership with managed care companies, greater opportunities for patient care present themselves,” explains Laura Ostrowsky, RN, MPA, CCM, director of case management at Memorial Sloan-Kettering.

In 2003, Ostrowsky set out to develop a patient advocacy program under her facility’s case management umbrella with the help of Robin Campbell, RN, MPA, insurance liaison manager at Memorial Sloan-Kettering.

Campbell and Ostrowsky knew the program would require a solid educational component for physicians and patients. To ensure a solid case for patient treatment, Memorial Sloan-Kettering’s case managers are diligent about:

• Collecting data on progressive treatments Memorial Sloan-Kettering performs that other facilities might not
• Analyzing the data to identify trends of success, which are later used to build a case for payers
• Determining how to present the data to get the best financial return from payers

We highlight this story, in detail, in our January issue of Case Management Monthly, but what are you doing at your facility to improve relationships with your managed care companies. What are some struggles you face?

CMW Tip of the Week: Communication is key with physician advisors

This week’s tip comes from Sharon Mass, PhD, ACM, and Donna Ukanowicz, MS, RN, ACM.

It is helpful for physician advisors (PAs) and staff members to have viewing rights to each other’s electronic calendars and be able to communicate via text messaging or e-mail. The most important element is to be able to touch base with each other at any given time during the working day. Determine the best mode of communication for different types of information. For example, if you need an immediate decision for an emergent need, you may wish to text with a contact number if verbal discussion is required. If the need is not urgent and can wait until the end of the day, you may wish to send an email and put in the header, “Reply needed by 5 p.m. today” or “FYI only” for information that does not need a response.

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: Case managers and core measures

This week’s tip, an “Ask the Expert” is provided by June Stark, RN, BSN, MEd.

Q: What role does the case manager play in coordinating and implementing core measures?

A: The primary barrier to having a case manager in this role is that it adds yet another responsibility to an already overburdened caseload.

If a case manager accepts the responsibility of becoming involved in the core measure process, this should not mean he or she becomes the leader of the project or carries out the core measures at the bedside. Instead, the case manager performs what is called “the sweep,” which is a final review of a patient’s chart.

This is the last opportunity to make sure all the core measures have been carried out and documented by the staff nurses and physicians throughout a patient’s entire hospital stay. In essence, the case manager has the final word on the completion and documentation of the core measures.

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: Data collection dos and don’ts

This week’s tip, an “Ask the Expert,” comes from Karen Zander, RN, MS, CMAC, FAAN.

Q: The social workers and case managers are spending too much time collecting data, and they don’t care about the data I show them. What should I, the director, do?

A: Do an inventory using a chart of the data they are collecting every day, which category of personnel collects it, how the data gets processed into reports, and who wants the reports—which may be more than one person or group. Then determine how important it is and to whom, which may take some conversations. Be willing to drop some element of the data collection if 1) it is not interdependent on another piece of information (an interdependency might be avoidable days as a partial explanation of LOS) and if 2) the data has no bearing on current decisions by you or the executive team (such as productivity measures that do not help you get more needed FTEs). And a huge consideration is that every piece of data costs money to collect and process and display and review!

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 reduce length of stay

Hospitalists create a win-win situation for themselves and the hospitals they work in, says Toni Brayer, MD, on eMaxhealth.com.

Hospitalists are physicians who typically work as part of a hospitalist group that provides coverage to a hospital seven days a week, 24 hours a day. Hospitalists become the attending physicians for  patients in the hospital—but only while they are in the hospital. Patients return to the care of a primary care provider after the hospital stay.

Brayer notes hospitalists often make more money working in the hospital than having their own practice. They are paid more by the hospital than they would receive by billing Medicare or Medicaid, and have no practice costs or employees to manage.

Additionally, hospitals with hospitalists programs have guaranteed coverage in the emergency department, better standardized protocols of care, and reduced length of stay.

Read the full article here.

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: 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!