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As more hospitals plan staff cuts due to the poor economy and tighter restrictions on reimbursement by the Centers for Medicare & Medicaid Services (CMS) and commercial insurers, case managers are challenged with determining how to demonstrate how their department positively affects the hospital's bottom line and to justify hiring new staff or avoiding staff cuts.
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Most of the staff in the new senior emergency center at Holy Cross Hospital in Silver Spring, MD, came from the main ED, says David Cummings, RN, CEN, the hospital's emergency center director.
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Hospitals and EDs that institute policies similar to the recent approach instituted at the University of Chicago Medical Center would do well to consider that they may be in violation of the Emergency Medical Treatment and Labor Act (EMTALA), warns Michael Frank, MD, JD, FACEP, FCLM, general counsel and director of risk management for Emergency Medicine Physicians (EMP) Management Group in Canton, OH.
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Several EDs across the country have initiated policies to encourage patients who don't face "true" emergencies to seek care elsewhere in the community and to find "medical homes," but none have been met with the outrage that descended upon the University of Chicago Medical Center recently.
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A few years ago, Christus Santa Rosa Hospital in San Antonio was $80 million in the red and was compliant with medical necessity and appropriateness of care criteria only 62% of the time, according to audits by the hospital's quality improvement organization (QIO).
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A pre-admission screening and educational program for patients having elective surgery has helped slash readmissions among patients treated at Geisinger Health System from nearly 20% a year ago to about 10% today.
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Case management outcomes can be a powerful tool for identifying the need for operational changes or process improvements throughout your hospital, as well as demonstrating the value of case management.
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At Summa Health System, hospital case managers, called patient care coordinators, often are the first people to alert the palliative care team when a patient could benefit from a consultation and the first people the team contacts to find out what's going on with a particular patient.
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A Six Sigma project to improve documentation of patient status has resulted in increased satisfaction, increased productivity, and decreased denials for Medicare reimbursement for Virtua Health, a four-hospital health system in southern New Jersey.
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As hospitals experience an increasing number of audits for medical necessity of admission, it's more important than ever to make sure that patients are in the appropriate status and that the medical record contains the documentation to support the status, says Deborah Hale, CCS, president and CEO of Administrative Consultant Services LLC, a health care consulting firm based in Shawnee, OK.