Understanding the insurance company case manager’s goals can help hospital case managers

While discussing a hospital admission with a case manager employed by a well-recognized national third-party payer, I learned of an interesting revelation that case managers may wish to take note of.

Each insurer-employed case manager is charged with meeting a monthly average length of stay goal set by the individual hospital as well as the aggregate hospital. The insurance case manager receives a weekly report of cases that achieved average length of stay compared to individually-assigned average length of stay goals and objectives. To this end, the case manager knows at any given time where he or she stands in regards to meeting the assigned goals for hospital length of stay.

This insurance company case manager informed me that he is reminded on a regular basis of the ramifications of not meeting the established monthly length of stay goals. In extreme situations, insurance companies will terminate case managers that do not meet objectives.

Depending on the time of month and how the insurance company’s case manager is faring, hospital case managers can expect different volumes of cases designated for medical director review and potential medical necessity denial. There exists a certain realism that insurer case managers and medical directors may err on the side of conservatism when using Interqual or Millman care guidelines and clinical judgment to determine denial of inpatient stays. The bottom line is hospital case managers will need to take inventory of their communication skills and core competencies, including drafting of effective, succinct denial appeal letters—if the hospital charges him or her with doing so as one of their duties.

In this context, hospital case managers should track and trend denials communicated by insurer case managers and understand these case managers need to achieve pre-established average monthly length of stay goals. Hospital case managers must prepare for increased inpatient stay denials given the current economic climate of private health insurers, decreased member covered lives, and resulting decrease in health insurance premium income. Increased medical loss ratios and the number of uninsured and underinsured patients seeking care through the emergency room with subsequent need for inpatient admission can also add to the number of denials.

I am certainly not advocating for case managers assuming additional work. At many hospitals, the administration assigns new tasks and assignments to case managers with the rationale being case managers already “review the record” and thus have the time to take on new responsibilities. Unfortunately, the case management function has become so convoluted that case managers find themselves regularly performing duties that questionably contribute to the role of case management. However, I am advocating for their development and reinforcement of core competencies and skill sets in the art of “forceful” communication and negotiation.

Identifying emergency department regulars can improve throughput

It would be safe to say that every emergency department (ED) sees a fair share of “frequent fliers” or those patients who seem to use the ED as an alternative to other healthcare resources in the community. Knowing “the players” or the clientele of the ED can help an ED case manager address issues that affect throughput.

In the past year, we at University Hospital, Upstate Medical Center in Syracuse, NY have put together a pilot program, patterned after programs we have seen in other hospitals. The hospital generated a list of frequent fliers in the ED during the previous six month period. We identified a group of patients who not only frequent the ED but also have primary care providers within the same hospital system. We used a team approach involving case managers and social workers in the outpatient setting, to address any barriers in the patients’ lives that may cause him to use the emergency department rather than the primary care office.

The expectation was that a social worker or case manager would see the patient each time one of theses patients presented to the ED or the outpatient setting. The social worker would document the reasons for the visit as well as any interventions in a shared file in the computer. We were all able to access that information daily, and keep tabs on the progress of each patient.

The goal is not to keep patients from emergency care. Sometimes those patients presented to the ED with legitimate emergencies, but often times a different setting would have been more appropriate. In the first six months we were able to decrease the number of ED visits in all the identified patients, and we saw an increase in the number of attended visits with their primary care providers. When the hospital generated list of frequent fliers in the next six month period, over half of the original patients were no longer on the list.

I believe that the ED case manager is a crucial part of the throughput process, and knowing the clientele can only enhance the productivity and efficiency in the ED.

CMW news: Incomplete discharge summaries to blame for preventable errors

A study released by the Indiana University School of Medicine finds that hospital discharge summaries lack information important to patients’ continuity of care.

Indiana University School of Medicine researchers published their findings in the September issue of Journal of General Internal Medicine under the title Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending Results and Outpatient Follow-up Providers.

The researchers reviewed 668 discharge summaries from two academic medical centers. They found that the hospitals discharged nearly 41% of the patients with test results pending—9% of those tests required changes with respect to patient care. However, the hospitals documented only 16% of those tests in patient discharge summaries. Only 13% of summaries included all pending tests.

Researchers say without that information, primary care physicians can’t provide the appropriate care patients need after discharge.

"Errors in communication reportedly contribute to over half of all preventable adverse events and are associated with twice as many deaths when compared with errors due to clinical inadequacy,” researchers conclude in their report.

Source: American Academy of Professional Coders and American Medical Association

Whiteboards help communicate across departments

Placing whiteboards at the foot of the patient’s bed was innovated by Planetree, a not-for-profit organization that works with hospitals to improve the patient experience and it has spread across the country.  Unfortunately, in most hospitals whiteboards stand blank except for some flower doodling. That’s a shame because whiteboards are a fantastic way for departments to talk to one another and the patient about the plan of care in a simple, direct, way.

The intent of whiteboards is much more than simply identifying discharge dates and times. The whiteboard is meant as a means of communicating the plan for the patient’s day—what tests, what new procedures, and medications the patient can expect on a given day. Just think, different caregivers can walk into a patient’s room and in a glance see what the attending physician has prescribed for the day. For the patient’s benefit, information written on the whiteboard should be in layman’s language. Patients don’t know what NPO stands for.

Using the whiteboard as a means to inform everyone of the patient’s targeted discharge is example of making sure everyone is on the same page regarding progression of care plans for the patient. According to nurses and case managers I have spoken with, the feedback from patient families is consistently positive.

However physicians are not always excited about whiteboards. In one client hospital, physicians were annoyed and complained to the CEO when staff members started using whiteboards to write patients’ plan for the day and targeted discharge. He was seriously thinking of putting a stop to their use, but the physicians’ complaints were quickly over-taken by the number of complements he received from patients, families, and hospital caregivers. Even dietary and housekeeping staff members endorsed the practice.  So, the CEO told the grumbling physicians to learn to deal with it….they are staying.

Does you facility use whiteboards? If so please share the ways you use them to communicate and how you handle HIPAA concerns.

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

Condition code 44 – The continuing saga

On August 28, CMS issued Medicare Claims Processing Manual (MCPM) transmittal 1803, which is the October 2009 update to the Outpatient Prospective Payment System (OPPS). CMS included minor revisions to those sections of Chapter 1 of the MCPM that relate to condition code 44.

As you will recall, condition code 44 is used when a patient’s initial inpatient status is successfully changed to outpatient for purposes of billing and payment. This generally occurs when case management and other utilization review personnel were not available (weekends and holidays) at the time that the admission decision was made, and it is later determined that the patient does not meet Medicare’s inpatient guidelines. Condition code 44 is reported on the subsequent outpatient (013X) type of bill that is submitted to recover for the services provided in the inpatient setting.

Those inpatient services are covered and reimbursed on the same terms and conditions as if they actually had been provided in the outpatient setting, so long as all of the following criteria are met:

• The decision to change status must be made by the hospital’s “utilization review committee” (UR committee). One “member” of the UR committee can make the decision, with the attending physician’s agreement; in all other cases, the decision must be made by at least two “members.” The change in status must be made prior to discharge or release of the patient and before the hospital has submitted a claim for the inpatient admission;
• A physician must concur with the decision;
• The physician’s concurrence must be documented in the patient’s medical record; and
• The UR committee must provide written notice to the hospital, the patient and the patient’s physician within two days (but not later than the patient’s discharge or release from the hospital) of the change and its impact on the patient, including financial liability for applicable deductible and coinsurance amounts.

In the transmittal issued on August 28, CMS stated that although one physician member of the UR committee is empowered to make the decision to change status, the physician member who makes the decision must be different from the concurring physician, who is the physician responsible for the care of the patient. Based upon this most recent statement, it is not clear what the effect would be if the physician responsible for the care of the patient did not concur with the change in status.

The regulations that set out the hospital’s conditions of participation (CoP), which call for the establishment of a UR committee, along with the scope of its responsibility and authority (including change of status), indicate that, in all other circumstances, the change in status decision must be made by two members of the UR committee. Presumably, this is the procedure that a hospital should follow if it were unable to obtain the agreement of the patient’s physician to change the status of care from inpatient to outpatient.

Hospitals are encouraged to have at least two signatures on the documentation for the change in status: (1) when the attending physician concurs, signatures of both the attending physician and the physician member of the UR committee who made the change in status decision; or (2) when the attending physician does not concur, signatures of the two physician members of the UR committee who made the decision to change status.

Hospitals are also encouraged to confirm with their FI/MAC that the process as outlined above, particularly when the patient’s physician does not concur, meets the requirements of a condition code 44 change in status.

Editor’s note: This article was written by Judith Kares, an, instructor for HCPro’s Medicare Boot Camp – Hospital Version. It was originally published on the MedicareMentor blog. Read the original post here.

Reduce Readmissions: Strategies to Improve Transitions of Care

As the population ages and more people develop chronic illnesses, healthcare professionals are challenged to balance patient needs and the bottom line with the government’s goals to reduce readmissions and improve quality.

Medication errors, missing or incomplete medical record documentation, and human errors that occur when patients fail to understand care requirements are just a few of the problems that can cause unnecessary readmissions. But by educating patients on their conditions prior to discharge—whether to home, a skilled nursing or other facility—and by taking simple steps post-discharge, providers can mitigate the problem.

To that end, HCPro will be hosting a live audio conference, “Reduce Readmissions: Strategies to Improve Transitions of Care,” on September 23.

This program taps the expertise of staff members Karen Mauro, LMSW, ACM, and Christina Pavetto Bond, MS, FACHE, of the Crouse Hospital of Syracuse, NY, who grew their comprehensive program in a nationally recognized model of care coordination.  They will show you how to audit and analyze your readmission data, provide tools to help you develop processes to reduce readmissions, and explain ways to reduce the likelihood of readmissions through pre- and post-discharge education. You’ll also learn valuable tips for effective communication with other providers and levels of care (e.g., primary care physicians, SNFs, and home health).

For more information on how you can reduce readmissions at your facility, visit HCMarketplace.com.

Providing care to undocumented immigrants

Without question, providing care to undocumented immigrants is a problem that leaves hospitals with few options. Because patients typically do not qualify for government assistance and cannot afford care, hospitals typically foot the bill for these patients, and sometimes the price can be in the millions.

A recent Healthleaders Media article, by John Commins, reported on one such a case. A partially paralyzed illegal immigrant was treated at a Martin Memorial Medical Center for three years before being transferred to his native Guatemala to continue his care. The hospital estimated the cost of treating the man to be around $1.5 million.

The patient’s family sued the hospital claiming that Martin Memorial illegally repatriated the man to Guatamala—a case they ultimately lost. To read more about the case visit the Healthleaders Media Web site.

In the same article, Mark E. Robitaille, CEO at Martin Memorial, said the issue of providing healthcare to undocumented immigrants remains unresolved on a state and national level, and he’s not optimistic that the issue of providing care to undocumented immigrants will be addressed soon.

“This is an opportunity for leaders at the state and federal levels to find a solution, rather than relying on individual healthcare providers to develop solutions on a case-by-case basis,” he says. “Unfortunately, none of the proposed national healthcare reform bills currently being debated in Washington address the issue of how to adequately provide healthcare for undocumented immigrants in a way that is fair and equitable to everyone involved.”

How does your facility handle undocumented immigrants? What resources are available to help your facility collect payment for these scenarios?

Need more info? Check out Caring for Uninsured and Undocumented Patients (Audio Conference).