Case Management

Sneak peek: Assign a surgery gatekeeper to ensure inpatient-only compliance

Case Management Weekly, May 11, 2011

Most facilities do not have a process to check scheduled surgical procedures against the inpatient-only list. This is 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 staff or someone trained in medical necessity criteria and CMS regulations should review all scheduled surgeries to be sure patients are 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.

Check out the June 2011 Case Management Monthly to learn more. You also can discover the benefits of becoming a Case Management Monthly subscriber.

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