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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.
In January 2007, the University of North Carolina (UNC) Hospitals in Chapel Hill implemented a standardized, electronic assessment tool to aid its case managers in providing thorough and consistent patient assessments.
Beverly Wagner, RN, BSN, CCM, ACM, clinical care management educator at UNC Hospitals, and colleagues developed the tool with staff members to ensure their buy-in. The result was the brief assessment tool (BAT). The BAT made documentation easier and more consistent; patient assessment documentation rose immediately. “We had a nice surge from about 8% of discharges having measurable assessment documentation to about 30%,” says Wagner. “But we kind of hit a plateau there.”
Check out the September 2009 issue of Case Management Monthly to read the full article, and discover the benefits of becoming a Case Management Monthly subscriber.
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When it comes to ED case management, it is possible to target certain populations for case management screening to determine involvement. These populations fall under the category of high-risk patients:
- Elderly fall
- Elderly extremity fracture
- Repeat visits for pain (back, abdominal, dental, migraines)
- Failure to thrive, frail elder
- Patients with multiple ED visits within the hospital-defined allotted time frame (e.g., more than two visits/month)
- Patients with readmissions within the time frames set by your facility (e.g., 48-72 hours from ED visit or inpatient admission, 30 days from inpatient admission, etc.)
- Patients with short- or long-term placement needs
- Patients with insurance red flags (e.g., managed care insurance plans, pay-for-performance insurance initiatives, uninsured/self pay)
To target specific populations, set up identifiers in the registration process to alert the case manager to targeted populations that may benefit from case management activities. Alerts can be set up and printed out as case manager worksheets.
Q: I am a case manager on a cardiac step-down unit. Our case managers’ work focuses primarily on l specific disease management and patient contact/education and nurse mentoring/chart reviewing, patient rounding, etc. We are very clinically focused.
We don’t do utilization review (UR) or discharge planning. We face the issue of case manager documentation. Legally, what must we document?
A: In this model, not doing utilization review allows the case manager to really focus on clinical progressions, which should be the focus of his or her documentation. The case manager should document how sick the patient is, and how the patient is progressing clinically each day. There’s no legal requirement for the case manager in this position to document, but there is a professional requirement to document the clinical progression as well as what the case managers taught the patient prior to discharge and how the patient responded. Every time they see, touch, or talk to a patient, the case managers should document.
This question was answered by Karen Zander, RN, MS, CMAC, FAAN.
With the economy in a downturn, most people are focusing on cost-saving efforts, and that goes for providers and payers alike. This is why a comprehensive understanding of hospital denials and their root causes will not only avoid front-end denials, but will also bring in revenue that may have gone unrecognized or been determined unrecoupable.
To effectively avert and overturn denials, it is imperative that case managers have a firm understanding of payer methodologies. Payer methodologies in reimbursements and denials can vary considerably, but case managers should have a clear comprehension of a payer’s expectations up front so they can build a strong case for medical necessity based on payer expectations.
To understand denials management, case managers should first understand basic individual payer utilization review (UR) rules and contract management. The best way to do this is to review UR payer and provider contracts, which are easily obtained from payers and providers. Case managers should review these to build an understanding of payer rules regarding status, billing, denials, and appeals.
Check out the May 2009 issue of Case Management Monthly to read the full article.
By Kimberly Hoy, JD, regulatory specialist for HCPro.
Q: A case management (CM) or utilization review (UR) nurse and the attending physician agree that the patient’s status should have been observation and the attending physician is ready to discharge that patient, but there is insufficient time to process it through the UR committee to obtain another approval if we are trying to comply with code 44 guidelines by writing the order prior to discharge. How should we handle this?
A: Condition code 44 requires a UR committee determination that a patient’s status should be changed from inpatient to outpatient, even if the attending physician is in concurrence. A representative of the committee may make this determination. However, the CM and UR nursing staff are not considered members of the UR committee for purposes of the Conditions of Participation (CoPs) so they may not be considered representatives of the UR committee. That leaves you in a very difficult position in the scenario you describe in which CM/UR nursing staff determines very close to the time of discharge that the patient’s status should have been observation.
Even though the attending physician agrees, condition code 44 and the CoPs require that two physicians make this determination. One may be the attending physician, but at least one must be a representative of the UR committee. In this situation, you may not be able to meet requirements for condition code 44 to bill the case as an outpatient, but all is not lost. CMS states in MLN Matters Article SE0622 that the appropriate billing method when you don’t meet condition code 44 criteria but the UR committee finds lack of medical necessity upon review of the case using CoPs guidelines is submission of the claim on a 12X type of bill. This type of bill allows payment for certain limited services (e.g., diagnostics, implants, dressings) under Part B when the stay was not medically necessary under Part A. Refer to the Benefit Policy Manual, Chapter 6, Section 10 for more information, including the complete list of services paid under the 12X billing methodology. This will require good communication with your billing department to distinguish these cases from condition code 44 cases, but affords hospitals the opportunity to receive some payment instead of writing the entire stay off as not medically necessary.
Going forward, the hospital may wish to consider asking physicians such as hospitalists, who are more readily available in these time sensitive situations, to serve on the UR committee. Alternatively, some hospitals find that a paid physician advisor, who serves on the UR committee and is on-call for consultation, is helpful when time is an issue. Physician advisors can be internal physicians on your medical staff with an interest in the UR committee. Alternatively, some companies provide contracted physician advisor services.
- One of the most important lessons Tanja Twist, MBA/HCM, director of patient financial services for Methodist Hospital in Arcadia, CA, learned from the demonstration project was the need to diligently track and monitor all correspondence to and from the RAC. “This goes beyond tracking the date you send or receive the actual documents (e.g., determination letters, medical record requests and appeals) or send the medical records, but should include tracking the receipt of the documents by the RAC to ensure you are responding timely.” Send everything via certified mail with a return receipt, she suggests. And make sure you are educating your entire facility-not just the mailroom-on what the RAC documents will look like so that correspondence will get to the right person or department. “Don’t assume that because you are able to identify a recipient for correspondence that the RAC will get it right every time,” she says.
- Tracking appeals was the single most important way to survive a RAC audit because it allows you to prioritize your appeals, says Stacey Levitt, RN, MSN, CPC, director of patient care management at Lenox Hill Hospital in New York City. “This way you can spend your available time where you get the biggest bang for your appeal effort.”
- Having a strong physician advisor program-not just having the concept on paper, but an available and active physician participant reviewing and interceding when appropriate-is critical for surviving RACs, according to Yvonne Focke, RN, BSN, MBA, revenue cycle director at St. Elizabeth and St. Luke Hospitals in Covington, KY. “Having such an advisor strengthens your compliance program which is more defensible when appealing cases, especially once they reach the Administrative Law Judge,” she says.
- It’s important for hospitals to regularly assess the effectiveness of their concurrent Medicare admission review processes, according to Joe Zebrowitz, MD, executive vice president for Executive Health Resources. Hospitals have to get the Medicare patient’s status correct every time. Establish a strong utilization review plan that follows Medicare’s Conditions of Participation. But a good plan does not solely ensure good results. You must make sure that the plan is being followed every day and that your case managers are using criteria to review all Medicare admissions and that every case that does not meet the criteria is undergoing a second-level review by a physician advisor, according to Zebrowitz. This physician advisor must be well versed in medical necessity regulatory guidance and use evidence-based medicine and risk stratification protocols to establish correct patient status. Your organization should also conduct retrospective audits on an ongoing basis to identify incorrect certifications from the past and self-disclose these errors, he says.
- Remember that RAC contractors are authorized to refer cases for investigation to the OIG when fraud or abuse is suspected, says Nancy Beckley, MS, MBA, CHC, of Bloomingdale Consulting Group, Inc.
- Take advantage of the 15-day rebuttal period prior to the actual appeals process, says Focke. “Even if only 10% of our cases were spared from this process, it was worth pursuing,” she says.
- Fran LaPrad, RHIT, CPHQ, director of health information at AdCare Hospital in Worcester, MA, had difficulty communicating with her RAC during the demo. LaPrad hopes communication will improve during the permanent program but suggests you should follow up voice mail messages with official letters if you don’t receive a phone call back within the allotted time.
- Zebrowitz also calls out the importance of physician education and collaboration. Many physicians working in hospitals do not have a firm understanding of the regulatory guidance on inpatient versus observation status certification and, more importantly, the ramifications of getting the status wrong, he says. It is your hospital’s responsibility to educate your physicians on the importance of documenting all of their concerns and findings in order to demonstrate medical necessity for all inpatient admissions. You also need to encourage strong collaboration between treating physicians, case management and physician advisors as they work to correctly certify each Medicare admission, ensuring that your hospital will be in compliance with the law and reimbursed appropriately, says Zebrowitz.
- The care management department at is becoming more and more important as the RAC program moves forward, says Focke. “Historically, care management departments have had a difficult time in justifying their existence because they were seen as a cost center that did not generate revenues,” she says. “But the value of having a compliant program has escalated with the advent of RACs and other regulatory agencies.”
- If you have the capability, scan all documentation to and from your RAC (including your medical records), says Twist. As you move through the appeals process, you will find that having the documents stored electronically will ease the process, she says.
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