Denials drop when CMs, MDs act as a team
Denials drop when CMs, MDs act as a team
Study shows value of collaboration
A study conducted at Good Samaritan Hospital in Dayton, OH, has determined that denial rates are lower when case managers collaborate with physicians to determine patients' admission status.
Marlyn Bledsoe, MHA, RN, a nurse case manager at the 577-bed hospital conducted the study as her master's thesis. For the study, Bledsoe compared the denials at the hospital during a pre-intervention period, which was 15 months when physicians determined the status with no input from case management, with Intervention A, which was the 15-month period when emergency department case managers reviewed every admission for patient status, and Intervention B, which is the current practice: Case managers recommend the status, and physicians have the ultimate decision.
Bledsoe was on a case management team several years ago that developed a standardized admission process in which every admission, regardless of the access point, was reviewed by a case manager for patient status. "But Medicare changed the game and issued a ruling that physicians, and not case managers need to decide on the status. I looked at this as a good opportunity to conduct a study to investigate whether case managers can have an impact on medical necessity denials," she says.
For the study, Bledsoe analyzed 10 DRGs that had a denial rate of greater than 2%.
The greatest number of denials occurred when physicians were ordering the patient status with no input from case managers and when there was true collaboration between the case manager and the physician (Intervention B), the denial rate went down, the study concluded.
When case managers were determining the status (Intervention A), the denial rate decreased in seven of the 10 DRGs. The three diagnoses where case management intervention had no effect on denials were laparoscopic appendectomies, hypertensive emergencies, and ante partum nausea, vomiting and dehydration. In most cases, the case manager simply did not have enough information in the emergency department to make a medical necessity determination.
"In Intervention B, when case managers communicated with the physicians, there was a further decrease in the denial rate, especially in the area of laparoscopic surgery," Bledsoe says.
Bledsoe cautioned that some data may be different in the future because the two-year period during which the Medicare and Medicaid Recovery Auditors Contractors (RACs) can request records has not expired for cases in the Intervention B group.
Denials went down under Intervention B, denials in every area except one: chest pain. There was close to a 2% denial rate for chest pain in all three intervention areas. When Bledsoe analyzed chest pain denials, she determined that the family practice groups and internal medicine doctors were admitting patients in inpatient status even with the recommendation of observation by case managers.
The study points out the opportunity to work with targeted groups of physicians and educate them on medical necessity criteria and the importance of correct patient status, Bledsoe says. The case management department's next target is to work with family practice groups and internal medicine physicians, she says.
Current literature suggests that there is an increasing trend for observation to be overused, says Michele L. Marshall, MS, RN, CNS, NE-BC,CPHQ, senior health services researcher at Good Samaritan Hospital's Center of Outcomes Research and Clinical Effectiveness. "This practice results in lower reimbursement for the services the hospital provides, increase in co-payment amounts for many patients, and it can mean that patients don't meet Medicare's three-day rule for post-acute services. Case managers have an opportunity to educate physicians on the financial impact of incorrect status, and to promote physician collaboration on determining patient status," she says.
Physicians haven't been trained on medical necessity criteria and they are going to treat patients the same regardless of whether they are in inpatient status or receiving observation services. There's a new set of medical criteria rules every year and physicians don't have the time to educate themselves on the changes, she says.
Bledsoe adds: "Case managers have the knowledge base to correctly determine the patient status. We should take the opportunity to look for trends in our denials and educate physicians on the importance of getting the status correct," she says.
Source
For more information contact:
- Marlyn Bledsoe, MHA, RN, Nurse Case Manager, Good Samaritan Hospital, Dayton, OH. E-mail: [email protected].
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