Proactive approach keeps denials low
Before the case management department at Northeast Medical Center in Concord, NC, launched an initiative to cut down on denials, the hospital’s rate of avoidable days was as high as 12%. Now, 2½ years later, avoidable days have dropped to 8%, according to Dianne Hansford, RN, MSN, director of case management at the 475-bed hospital.
Northeast Medical defines avoidable days incidents as patients who do not meet admission criteria or those who had delays in treatment and discharge. "We wanted to avoid denials and delays in treatment and to improve our processes and procedures. We started by identifying barriers that impact discharge and compiling the major reasons for avoidable days," Hansford says.
The case management department at the hospital includes utilization review and case management. Some case managers perform traditional case management duties while others primarily perform utilization review activities. "We are very keen on identifying and eliminating potential barriers to care," she says.
Concurrent denial management
Using the MIDAS+ care management system software from Dallas-based Affiliated Computer Services Inc. (ACS), the case management department began monitoring avoidable days. The case management staff concurrently review about 90% of Medicare patients, all requested privately insured patients, as well as Medicaid and self-pay patients to determine avoidable days. "We review the majority of patients in the hospital," Hansford says.
The case management department performs concurrent review and concurrent denial management every day, adds Jo Ellen Inman, RN, BSN, MBA, utilization review case manager. "We take a proactive approach to avoidable days, and that is one reason we are able to keep our denials and avoidable days so low," she adds. As a utilization review case manager, Inman reviews all insurance requests within the same calendar day, unless the patient is having a procedure, then she conducts the review within 24 hours.
Inman sees all patients and reviews all charts within three days. "We have to be proactive and not reactive. Once a Medicare denial occurs, it’s not recoverable."
The utilization review case managers typically do not interact with the patients. Instead, they call on the physician-based case managers when a question arises.
Finding avoidable days
"As a utilization review case manager, I see what is on the paper, what the payer will see. I have that perspective, but I also can interact in real time with the case managers [who see the patients in person and] who have the real picture and the ability to interact to minimize avoidable days," she adds.
In many cases, the problem that Inman picks up on is simply an issue of having the physician document or go into more detail on the chart. "But having another set of eyes, another clinician, review the case also serves as a quality check in case something has been overlooked."
The case management department sends regular reports to the hospital’s resource utilization subcommittee and gives input to the medical staff on patients who didn’t meet InterQual (McKesson Health Solutions, Newton, MA) criteria or when treatments or protocols aren’t followed. Each case manager reviews her cases to find avoidable days every week and turns in an avoidable days report. The department reviews each case manager’s report as a team to make sure there is a consensus that the information is valid and that the days could have been avoided.
Initiatives launched
When there are gray areas, the case management team goes to the resource utilization committee, asks it to review the incident to determine if it agrees there was a problem, and asks for suggestions on how it could be solved. "We may say this patient could have been treated as an outpatient or in a different arena," Hansford says.
Every three months, Hansford’s department takes a close look at trends in delay in treatment and denials to determine if there are specific areas where problems occur. "We work so closely with doctors that we have to look for the little problems, not the big problems. The physicians have done a good job in appealing denials, so the denials aren’t a big problem," she says. After reviewing the avoidable days, the case management department launched a series of initiatives to help avoid them.
The case management staff alert physicians and physician-based case managers whenever avoidable days occur to help them recognize and avoid future problems. This includes patients who didn’t meet the admission guidelines as well as those who could be discharged to a less intensive setting than a hospital, Hansford adds.
Staff zero in on specific problems and take steps to correct them. For instance, when the case management department looked at unnecessary admissions to the intensive care unit (ICU), it focused on patients admitted with gastrointestinal bleeding. "We looked at the reasons for admission and found out that several people were being admitted to the ICU when they didn’t need to be in there based on their blood work," Hansford says.
Reasons for admission
The case managers took their findings to the resource utilization subcommittee, which includes physicians, and helped rewrite the protocol for gastrointestinal bleeding. "Now we look at mental status, orientation, how stable they are, and how much blood has been lost instead of using just the blood work as the criteria," she says.
If a patient with gastrointestinal bleeding has hypertension, he or she still may be admitted to the ICU, but if the patient is stable, he or she is sent to the medical unit with orders to be monitored closely. When the committee examined the data again, there was a significant improvement.
The case managers look closely at all ICU patients, reviewing guidelines and criteria and checking the patient charts. "For instance, if coronary care patients’ heart rhythm is stable and they’re not having any problems, they could go to the medical-surgical unit," Hansford says. When case managers encounter patients who could be at a lower level of care, they talk to the physicians, get the documentation, and work to make sure patients meet the severity of illness criteria.
"We look very carefully at the charts. Sometimes, there is no documentation to support the current level of care. We then talk with the physician, and if there still is no justification, we conclude that the patient could have been at a less intensive level of care or not been there at all," she says.
Addressing documentation
The team worked to determine why delays in treatment and procedures were occurring. It looked at whether the delays with various diagnoses were caused by problems with the admissions guidelines or treatment guidelines. For instance, one problem was a delay in surgery for cardiac catheterization patients who were admitted on Saturday and had the catheterization procedure on Monday. The team compared the cost of the delay for the treatment and the cost of doing cardiac catheterizations on Saturday. "We did a cost-benefit analysis and determined that there was not significant enough savings to call a team in on Saturdays except in the case of imminent need or an emergency," she adds.
Many of the avoidable days were due to patients who needed to be admitted but were admitted under the wrong status. For instance, physicians would admit patients for observation; however, for the hospital to get appropriate reimbursement, they should have been admitted on an inpatient basis, Hansford says.
To alleviate the problem, the case management team created pocket cards for the physicians based on InterQual parameters of care for observation vs. inpatient admission status. "It helped the physician to better understand the level of care patients needed to be admitted under. We still work with them closely and work with the emergency room staff on point-of-entry case managers," she says.
Lack of documentation or inadequate documentation to support severity of the illness is another frequent problem. When this occurs, the case managers give the physicians suggestions of what would support medical necessity. They point out what needs to be documented for reimbursement purposes.
The hospital has established a compliance documentation program that looks at what a patient is being treated for and how it is worded on the chart. It looks at whether the patient has an acute care plan and what is anticipated post-surgery, such as a possible postoperative hemorrhage.
"We work with other agencies that grade the hospital, based on coding. Coding is based on documentation. We know how critical documentation is, and we are focusing on improving it," Hansford says. A close working relationship with the physicians is a key to cutting down on avoidable days, she points out. "Our case managers are physician-aligned and have an incredible working relationship with the medical staff."
The case managers work with the physicians on other options, such as performing some diagnostic procedures on an outpatient basis. They look at criteria and point out what the orders should be to prove medical necessity. For instance, a patient with a stroke must have orders for neuro checks. "Most of the problems we find are little things. Often, we find that the patient needs to be here but the physician must write certain things into the record. We keep reminding the physicians that we have to prove why the patient is here and what treatment we are doing to justify keeping them here," Hansford adds.
Ongoing relationship
When the hospital gets a denial, staff look at why the patient was admitted and what should have been documented to meet medical necessity. They take the information to the physician. "We have an ongoing relationship with the physicians, and there is an element of trust and rapport between them and the case managers. It’s not like we are policing them or trying to manage the care of their patients. We are helping them to better document the severity of illness of their patients," she says.
Inman came to Northeast Medical Center from another hospital where she worked on the denial recovery team. She gives kudos to the administration at Northeast for putting the resources behind the case management team. "You have to put in the labor expenses before you can see the financial benefits of managing avoidable days," she adds.