Case Management

Investigate gray areas to improve patient status assignment

Case Management Monthly, June 1, 2011

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Not every patient status decision is difficult. Some are quite obvious.

"I don't think a hospital has ever received a request for a medical necessity review of a patient in the ICU intubated on a dopamine drip," said Ralph Wuebker, MD, MBA, vice president of audit, compliance, and education for Executive Health Resources, during the April 5 HCPro, Inc., audio conference, "Short Stays: A Data-­Driven Approach to Medical Necessity."

But Recovery Audit Contractors and Medicare Administrative Contractors (MAC) are not concerned with simple patient status decisions. They focus on the cases that fall into the gray area of patient status.

Facilities that do not have a strong Medicare admission review process will struggle to get these cases correct and defend them should they come under scrutiny, Wuebker said.

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