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A readmission reduction collaborative of San Francisco Bay-area hospitals and their post-acute partners has reduced hospital readmissions by 20% among participating hospitals, preventing more than 4,000 readmissions.
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Patient access areas are seeing more procedures requiring authorization, a surge in the number of insured patients, and more clinical requirements from payers. All of these factors make an increase in claims denials and much lost reimbursement very likely.
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Prior to the advent of the inpatient prospective payment system (IPPS), the discharge planning process was simpler and slower. Patients generally stayed in the hospital until they were well and then went home.
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Implementation of ICD-10 has been postponed until Oct. 1, 2015, and all claims submitted after that point must use the new coding system.
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The Centers for Medicare & Medicaid Services (CMS) has announced a pause in the Recovery Auditor program while it develops new contracts with the auditors, and so the auditors can complete all claims reviews before the current contracts expire.
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After St. Rose Hospital in Hayward, CA, started its readmission reduction program, the community hospitals 30-day readmission rate for all diagnoses dropped by 37% and the 90-day readmission rate declined by 43%.
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The Centers for Medicare & Medicaid Services Probe and Educate initiative to determine hospitals compliance with the two-midnight rule makes it clear that case managers must review physician documentation as well as medical necessity.
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Case managers have been an integral part of the discharge planning process for decades. Typically this process has involved an in-depth assessment of the patient, which has included their clinical as well as psychosocial, financial and living situations
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When BK Kizziar, RN-BC, CCM, was in the hospital following surgery, a case manager walked into her room the day before discharge and asked whether she wanted to go to an acute rehab facility or have physical therapy sessions at home.
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Bioethicists can advocate for improved communication with family caregivers when a patient is going to be discharged from the hospital.
