All Entries Tagged With: "data collection"
Are you paying attention to your case mix index?
What is Case Mix Index (CMI) and why, as a case manager, do I care what that is? According to the Financial management for nurse managers and executives (3rd ed.), CMI is the measurement of the average severity of illness of patients treated by a healthcare institution. Basically, CMI helps determine the dollar amount assigned to a diagnosis related group (DRG) for the Medicare population. Medicare assigns a dollar amount for every facility, which is partially determined by the CMI.
Hospitals use the CMI to determine the budget, and if the actual CMI is lower than the budgeted CMI, the incoming money for those DRGs will be less. This causes an imbalance in the hospital revenue. If the money isn’t coming in as planned, a financial fiasco can occur. Think of CMI as the yellow light that warns the hospital of any impending decrease in hospital income. The financial wizards and senior management monitor the CMI on a monthly basis.
Appropriate DRG assignment for each inpatient case impacts the CMI. This is another reason why complete and accurate documentation is important. Coders need thorough documentation to assign the appropriate DRG. Appropriate coding determines the DRG, and the average DRG weight determines the CMI. Case management and clinical documentation improvement specialists can help the coding team by ensuring documentation supports the appropriate diagnoses, which will lead to appropriate assignment of a DRG.
CMI is complex, but essential to the revenue survival of hospitals. CMI is used to adjust the hospital’s average cost per patient. CMS uses the annual CMI to determine the DRG amounts for the next year. CMI is a very complicated concept to grasp, but it is important to remember that CMI is a tool that is used to predict income, outlines patient types, and helps explain the cost of treating a hospital’s population. In the end it goes back to complete, accurate and timely documentation and appropriate coding practices.
Do you know what your institution’s budgeted CMI is and what your actual CMI is?
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.
Readmissions data now reported by CMS
CMS released a statement on Thursday, July 9, saying that its Hospital Compare Web site will now contain data reporting how frequently patients return to a hospital after being discharged, “a possible indicator of how well the facility did the first time around,” says the statement.
The statement goes on to say that, on average, one in five Medicare beneficiaries discharged from a hospital is readmitted within a month. President Obama and Congress are focusing on reducing readmissions as a way to improve quality and achieve cost savings, according to the statement.
Hospital Compare data show that 19.9% of patients admitted to a hospital for heart attack treatment will return to the hospital within 30 days, 24.5% of patients admitted for heart failure will return to the hospital within 30 days, and 18.2% of patients admitted for pneumonia will return to the hospital within 30 days.
“Research has shown that hospital readmissions are reducing the quality of healthcare while increasing hospital costs,” the statement reports.
CMW Tip of the Week: Case management deliverables
This week’s tip, an “Ask the Expert,” comes from Karen Zander, RN, MS, CMAC, FAAN.
Q: Why does case management have to prove itself with deliverables?
A: Case management is in a position of having to continuously defend and justify its existence. This saps energy and distracts from case management’s full potential. Because it is relatively invisible, the director must constantly present data, educate the executive team about options, and negotiate resources to do the job well. Through the executive team, and ultimately the CEO, the board will eventually learn about the ever-increasing value of case management services. [more]
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: HIM can help you de-code data
This week’s tip comes from Harriet Kinney, RHIT, CHC, organizational integrity manager for Trinity Health in Novi, MI.
Case managers should team up with their health information management (HIM) department when looking at data. There’s usually somebody in HIM, such as the HIM director or a sharp analyst, who can help talk case managers through what they’re looking for. This can be especially useful when it comes to getting data for all pneumonia cases, for example.
The way a nurse may think of a pneumonia case is not necessarily how the bill went out the door, because of the DRG. A nurse case manager may think, “Well, Mr. Smith had pneumonia” but actually pneumonia was one of the many secondary conditions that were being treated. After careful study it is revealed that pneumonia was not the reason Mr. Smith was admitted to the hospital. He was admitted because he had a myocardial infarction (MI). The bill goes out saying his principal diagnosis was an MI, and the pneumonia code is listed somewhere down in secondary diagnoses.
Therefore, speaking with somebody in HIM will help case managers understand how claims go out or how the data from coding goes out.
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!
