Training Programs
Audits & Assessments
Regulatory MonitoringArchive for July, 2008
To read a story on the Patient Access Resource Center that features important terms and definitions of the Medicare Secondary Payer Questionnaire, click here.
In this piece from the Wall Street Journal health blog, the author asks whether long emergency room waits are good for a hospital’s bottom line.
The author notes that patients who show up at the emergency room are less likely than patients admitted to the hospital by a staff physician to need lucrative, procedure-driven care.
Because a hospital has only so many inpatient beds, it may make economic sense to fill the beds up with the lucrative, well-insured patients admitted by staff physicians, he says.
To read the full blog in the Wall Street Journal, click here.
They may not continue them in their nationwide rollout starting in 2010, but the Medicare Secondary Payer Recovery Audio Contractors (MSP RACs) took back $12.7 million in MSP overpayments in the three-state demonstration project that ended in March.
As a patient access manager, you need to be prepared now for the nationwide rollout of RACs. More than $1.03 billion in Medicare improper payments were collected – $980 million in Claim RACs, and $12.7 million in MSP RACs.
CMS decided to discontinue MSP RACs and include MSP issues in the jurisdiction of the other RAC contractors.
However, compliance with MSP requirements is more crucial now than ever. And that means better training and ensuring staff competency through testing before the RACs come to your hospital, patient access experts say.
“When it comes to filling out the Medicare Secondary Payer Questionnaire, it is critically important to make sure that you complete all the fields accurately and completely,” says Michael S. Friedberg, FACHE, CHAM, director of Patient Access Services at Apollo Health Street in Bloomfield, NJ. “Incorrect completion of the forms can result in Medicare’s incorrect selection as primary payer. On audit this can subject your facility to a negative financial impact.”
For more on this issue, see Patient Access Resource Center’s lead story in its September newsletter.
To view a report from CMS on the RAC demonstration project, click here.
CMS is splitting a $49 million grant between high-risk Health Insurance Pools (HIPs) in 31 states. The money was divided based on the number of HIP enrollees in each state, and is intended to help increase access to healthcare by assisting individuals who are uninsured and unable to obtain health insurance due to serious or chronic medical conditions.
The premiums for the HIPs can be very expensive—around $700 per month for an individual. Still, the programs often operate at a loss.
The grants will help offset the costs for deserving individuals and will help make up some of the losses of the program.
Sources: Kaiser Daily Health Policy Report, Salt Lake Tribune
If you’re a Medicare patient, your doctor may not be willing to take a quick look at your sore throat when you go in for an appointment about your blood pressure. Some physicians are making patients book separate appointments for each of their ailments.
Medicare reimburses according to the number of appointments and physicians are being forced into creative scheduling in order to treat their Medicare patients, according to The Tennessean. Medicare does not factor in the amount of time the physician spends with the patient during each appointment. The increased number of appointments for each patient often translates into months of waiting to be seen and less effective primary care, which can mean more visits to the hospital.
Other money-saving tactics physicians are using include not accepting new Medicare patients and cutting current Medicare patients. Patients with chronic conditions who are on Medicare and can’t find a primary care physician will be forced to visit already over-crowded emergency departments.
Still, not much is being done to remedy the problem. The Medicare reimbursement schedule is determined by a formula created in 1997 and only Congress can override it.
Source: The Tennessean
This week’s tip comes from Linda O’Neil, RN, BSN, CCM, director of care management at Mercy Hospital in Bakersfield, CA.
One thing I have found is my case managers often become the “go to” person for the nursing staff on the floors (my case managers have offices near the nurses’ station on each floor.) To enhance this relationship, we have interdisciplinary rounds each morning in the case manager’s office at 0900. This process involves the case manager, the nurse manager for the floor, the charge nurse, and the nursing staff. The RNs come into the office one at a time and give a report on their five patients. This is not the standard shift change report. This report requires the RN to state only why each patient needs to be in the hospital on that day. If he or she doesn’t know, the case manager can explain why the patient should or should not be at this level of care.
The case managers have been asked to be extra friendly and helpful to the staff when they are teaching them some of the criteria they need to know. This process tends to cement the relationship between the case mangers and the floor staff. An added side benefit is that after a few weeks of this process, the staff nurses start coming into the case managers’ offices and telling them a particular patient really doesn’t meet criteria and needs to be moved to a lower level of care.
Have a tip you’d like to share? Or maybe a question for our experts? Email it to editor jmcginley@hcpro.com.Your thoughts could be featured in the next issue of Case Management Weekly!
For patients to receive the right care and to deal with the effect that an injury or health problem can have on other factors in their lives, such as work and family, it is often critical that a case management program staff both RN and social work case managers.
However, the two professional disciplines often don’t know how to use each other, forget to take advantage of the services the other offers, or feel territorial about which cases belong to which discipline.
Susan Reynolds, MSW, CCM, is one of two social work case managers who work with a team of 15 or 16 RNs as part of Passport Health Plan’s case management program in Louisville, KY. Reynolds says she feels valued and respected at her organization. “I have never felt that there were any issues with turf here,” she says.
Gretchen Uhl, RN, CCM, is an RN case manager who works with Reynolds and understands the value of working with social work case managers. “They’re very knowledgeable, and they have different experience. They give me a completely different perspective on the problems that I might run in to with my patients.”
As to how this synergy of social workers and RN case managers came about at Passport, Reynolds and Uhl attribute it to the following administrative differences:
- Nurse and social work case managers are paid the same and are considered to have equal but different levels of expertise.
- A low turnover rate.
- Upon orientation, a new staff member is required to shadow each member of the department, including the social workers, or, in the opposite case, the RNs. In this way, the new staff member understands what each person’s function is and how each side works.
Check out the July 2008 issue of Case Management Monthly to get the full story, and check out all the benefits of being a Case Management Monthly subscriber!
A report slated for release on Thursday claims the U.S. has the most expensive healthcare system in the world, according to The New York Times. The report also notes that the U.S. spends twice as much per person on healthcare, compared to other industrialized nations. The report is the second of its kind done by the Commonwealth Fund, a non-profit research organization in New York City.
The report emphasizes the inefficiencies of the American system. For example, in the U.S., about 7.5% of healthcare payments go to administrative fees. If the U.S. could get that down to the 5% it is in other industrialized countries, it could save about $50 billion a year, say the authors of the report.
The findings are expected to inspire political candidates to make more healthcare reform promises during their campaigns, according to The New York Times.
Sources: The New York Times, The Commonwealth Fund
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