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Regulatory MonitoringAuthor Archive
Oct
28
By Loretta Sandy, PhD, RN, CCM
One of the primary rules physicians and nurses learn in school is "if it is not documented, it is not done." Another concern expressed by medical professionals in our litigious society is "remember that you may need to defend what you charted in a court of law." Finally, attorneys caution healthcare professionals that the more they chart, the more they may have to defend.
Although these statements are not contradictory, healthcare professionals are typically cautious. However, with the implementation of RAC audits, documentation must be comprehensive because it helps ensure that hospitals receive fair and justifiable reimbursement.
Given the potential effects of a RAC audit, healthcare professionals must understand why they should carefully document the following:
- Presenting symptoms
- Rationale for a particular level of care
- Treatments provided to improve a patient’s clinical status
Healthcare professionals must also substantiate their clinical judgment as to why a patient needs to remain in a given level of care on a daily basis. The case manager should confirm that the documentation is accurate and consistent with the hospital’s level-of-care criteria (e.g., Milliman, Interqual). If clinical documentation is not consistent with screening criteria, it must define the rationale for treatment decisions.
Check out the November 2009 issue of Case Management Monthly to read the other creative ways to reduce LOS. You can also discover the benefits of becoming a Case Management Monthly subscriber.
Oct
21
by June Stark, RN, BSN, MEd
Strategic innovations for reducing length of stay (LOS) that have emerged in recent years provide a wide range of choices for case managers.
Many innovations have become predictors of success and may enhance hospital throughput from the ED door to discharge. These initiatives also cross the entire healthcare continuum, providing case managers with the opportunity to select initiatives that have a focused effect on LOS.
I’ve listed many of these initiatives in chronological order, from the beginning of the hospital-based continuum to the conclusion of the stay:
- Institute preoperative admission screening for all elective surgeries to decrease LOS. Positioned on the front end, the case manager meets the patient and/or family and sets hospital expectations along with preadmission discharge planning.
- At the time of admission, a unit-based case manager assignment model is more reliable for reducing LOS when compared to specialty case manager assignment. The advantage of unit-based case management is that the case manager is present to ensure completion of all discharges. Specialty-based case managers often follow a physician group’s patients from one unit to another. A case manager’s travel time can average approximately 90 minutes, according to published reports.
Check out the November 2009 issue of Case Management Monthly to read the other creative ways to reduce LOS. You can also discover the benefits of becoming a Case Management Monthly subscriber.
Oct
14
CMW tip of the week: Establish a relationship with patient financial services staff
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Patient financial services (PFS) counselors offer various assistance to patients. They:
- Speak with patients about insurance coverage or the lack thereof,
- Offer to assist with originating a Medicaid or free/charity care application, and
- Try to answer any questions related to the financial obligations resulting from the patient’s ED visit/hospitalization.
ED case managers also can inquire about other funding opportunities available through:
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Workers’ compensation
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No-fault motor vehicle insurance
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State crime victims’ insurance funds
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Charity care, such as professional home visits, durable medical equipment, or free transportation
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Individual state public health resources
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Individual hospital funded programs for post acute needs
Establishing a relationship with PFS counselors can help case managers in their role as patient advocates.
This tip was adapted from the HCPro publication Emergency Department Case Management. For more information or to order your copy visit the HCMarketplace.
Have a tip or tool you’d like to share or maybe a question for our experts? E-mail it to editor Ben Amirault at bamirault@hcpro.com.Your questions or comments could appear in a future issue of Case Management Weekly.
Oct
14
The decline in tax revenue and increase in Medicaid enrollment combined to put the squeeze on the Medicaid budget for many states.
As a result, 13 states will reduce Medicaid pay for physicians in fiscal year 2010. They include: Georgia, Louisiana, Minnesota, North Carolina, Vermont, Wyoming, California, Utah, Washington, Colorado, Hawaii, Maryland, and Ohio..
In fiscal year 2009, Medicaid enrollment grew by 5.4% and total program spending increased by 7.9%, the fastest pace in five years. Without the federal stimulus bill, the current economic climate would have forced states to cut Medicaid funding even more drastically. That additional federal funding for Medicaid runs out December 31, 2010. This has Medicaid directors worried about cuts that may be in store for fiscal year 2011.
Source: American Medical Association
Sep
30
Reevaluating an existing emergency department case management program is the first step toward strengthening it and ensuring that it meets the needs of patients and the ED. Consider the following program elements:
- Presence/availability of the case manager
- Do staff members think that the case manager is readily available to help them?
- Does the case manager respond quickly to consultation requests?
- Is a staff satisfaction survey about case management services necessary?
- Collaborate with ED staff with respect to best practice guidelines:
- Does an opportunity to develop best practice guidelines or clinical pathways (e.g., interdisciplinary care of the alcoholic patient) exist?
- Meeting ED case management needs:
- Do case management coverage hours meet ED and patient needs?
- Would changing or extending hours improve patient flow/quality care?
- Do you need to reevaluate data you collect?
Have a tip or tool you’d like to share? Or maybe a question for our experts? E-mail it to Editor Ben Amirault at bamirault@hcpro.com.Your thoughts could be featured in the next issue of Case Management Weekly!
Sep
23
Patient safety and well-being, pending regulations, and smoother discharges are all reasons for developing relationships and sharing information with outside agencies.
Crouse Hospital in Syracuse, NY, had these goals in mind when it developed Care Express, an electronic online tool that allows home care agencies and SNFs to access patient records.
Sep
23
If your facility has identified the need for a physician advisor (PA), a great place to begin searching for the ideal candidate is within your organization.
Hiring a physician who has been on the medical staff for at least three to five years may be beneficial. These individuals already know the hospital system, physicians, policies, and politics.
Determine which active medical staff members are very knowledgeable with respect to medical necessity and length of stay (LOS) issues, practice high-quality evidence-based medicine, communicate effectively, and use hospital resources responsibly. Then observe them during committee and department meetings to assess how they relate to their peers. Once you identify individuals who meet these qualifications, approaching them to inquire whether they have interest in working as a PA might be worthwhile.
This tip was adapted from the HCPro book, Optimizing the Physician Advisor in Case Management. To learn more about this book or order your copy, click here.
Sep
09
By Judith Kares, an regulatory specialist for HCPro, Inc.
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 the services provided in the inpatient setting.
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