Case Management

Assign a surgery ­gatekeeper to ensure ­inpatient-only compliance

Case Management Monthly, June 1, 2011

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Most facilities do not have a process in place to check scheduled surgical procedures against the inpatient-only list. That's where a case manager dedicated to the surgical unit can help, says ­Ronald Hirsch, MD, FACP, medical director of case management at Sherman Hospital in Elgin, IL.

Case management or someone trained in medical necessity criteria and CMS regulations should review all scheduled surgeries to be sure the patient is scheduled in compliance with Medicare guidelines, Hirsch says.

"There is too much money at stake to not do this. ­Unfortunately, many hospitals will not learn this until the [Recovery Audit Contractors] start taking back the whole payment for surgeries done in the wrong ­setting," he adds.

Some facilities, such as Port Huron (MI) ­Hospital, have a full-time case manager who scrutinizes the ­surgical schedule, and they have seen great results, says Rochelle Schiller, RN, MBA, director of care ­management at the facility.

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