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Tip: Inappropriate bed assignments contribute to denials

Patient Financial Services Weekly Advisor, April 8, 2005

Mary Johnson, RN, BS, CPHQ, came to Maine Medical Center in Portland in January 2003 facing more than $4 million in clinical denials. As the facility's clinical denials program coordinator, her mission-in theory-was simple: Reduce denials and increase this 607-bed facility's bottom line.

One of her first steps to this end was an attempt to improve the facility's process for assigning patients to inpatient or observation status.

Johnson looked to the facility's ED case manager, who is the first line of defense against inappropriate bed status. "She's the gatekeeper," Johnson says. "She is one of the first to determine whether the patient meets the criteria [for observation or inpatient status]."

Following that lead, Johnson took an interdisciplinary approach to train all staff in case management, medical records, nursing, admissions, and information technology. You can follow her lead:

1. Develop a grid system.
At Johnson's suggestion, Maine Medical employed a patient-admission grid that was designed to help clinicians determine appropriate patient type. The grid uses clinical standards such as the Milliman Care Guidelines, Interqual Level of Care, and Medicare Inpatient-Only List.

For example, an abdominal hysterectomy is an inpatient-only procedure, but a vaginal hysterectomy is considered outpatient, Johnson says. "Surgical bookings are done by people in surgeons' offices, and they call someone in central booking. The central bookers are not clinical, so it's difficult for them when clinicians say 'book this surgery' to know the difference."

2. Educate clinicians on how to use it.
Next, Johnson educated caregivers about how to correctly use the grid and assign patients to the appropriate bed type. She implemented a program to teach ED nurses about the criteria necessary to assign patients to either observation or inpatient status. Under this program, an ED nurse educator trains the nurses through an online course posted on the facility's intranet site; to complete the training, nurses must pass a test on observation.

3. Consider other tools.
Johnson also created stickers that spell out CMS's observation guidelines, which case managers place on patient charts.

The stickers serve to remind physicians that they need to place patients in the correct level of care as soon as possible to prevent delays. "If a patient is on the floor and the case manager can't catch the physician [to assign a bed status to the patient], she puts a sticker on the chart with her beeper number and asks the physician to call her as soon as possible," says Johnson.

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