HCPro.com - Case Management Weekly

CMW mentor moment: Promoting efficient use of resources and appropriate hospitalization length of stay to physicians, a different approach

Wed, 18 Nov 2009 05:00:00 GMT

The following article is an excerpt from HCPro’s www.CaseManagementMentor.com—a free blog dedicated to connecting hospital case managers to industry pacesetters, peers, and best practices.

Physicians sometimes acquiesce to family wishes and desires and admit a patient for social reasons. Conversely, physicians sometimes keep patients in the hospital an extra day because they express a desire to stay “just one more day.” These unnecessary, avoidable hospital affect potential revenue loss for hospitals when third-party payers deny days or deny hospital stays.

A major challenge in motivating physicians to move the patient along the continuum is the disconnect between the necessity for prudent hospital fiscal management and the practice patterns of physicians. The physician generally receives payment for his evaluation and management services regardless of whether the hospital is paid or denied for the patient care.

Change is on the horizon, however. CMS currently is considering provisions that will promote the efficient practice of medicine. Medicare and other third-party payers also are committed to transitioning from physician payment based strictly on volume to payment based on the relationship of quality, costs, and outcome. The efficiency and effectiveness physicians’ practice of medicine will determine their individual financial welfare and business success.

Read the rest of this post, or share your thoughts on this topic.

Browse more blog posts at www.CaseManagementMentor.com

CMW news: Providers report first RAC denials in Florida, South Carolina

Wed, 18 Nov 2009 05:00:00 GMT

Healthcare providers are starting to share their interactions with recovery audit contractors (RACs).

One South Carolina hospital reported three claim denials. However notification apparently was less than ideal, at least from the hospital’s perspective. In late October, the hospital received a call from Connolly Healthcare, the Region C RAC for South Carolina and several other states, regarding a denial letter. Despite Connolly’s claim that it sent the letter in early August, the hospital denied receiving it.

Connolly reportedly sent the hospital a new letter. The total take-back was less than $200.

Source: HealthLeaders Media

CMW tip of the week: Learn the physician advisor role

Wed, 18 Nov 2009 05:00:00 GMT

Editor’s note: This week’s tip is a Q&A that appears in the HCPro book Hospital Case Management Models: Evidence for Connecting the Boardroom to the Bedside. For more information about this book or to order it visit the HCMarketplace.

Q: How can a good physician who is interested in being a physician advisor learn the role?

A: Spending a few days with an effective physician advisor in a similar type hospital is one way. Finding a mentor to guide you for a few days during your first month in the position is another. Potential physician advisors also should also spend time with case mangers to learn their needs and review available data pertaining to physician and case management activities.

Undecided physicians should attend one of several national conferences that address the subject. They also can benefit from reading one or two of the leading texts specifically on hospital case management.

Have a tip or tool you’d like to share or maybe a question for our experts? E-mail it to editor Ben Amirault at bamirault@hcpro.com.Your comments or ideas could appear in a future issue of Case Management Weekly.

CMW sneak peek: Pilot program identifies the cause of frequent ED visits; patients overcome barriers

Wed, 18 Nov 2009 05:00:00 GMT

University Health Care Center (UHCC) in Syracuse, NY modeled its program for handling frequent ED visitors after one established at Swedish Medical Center in Englewood, CO, says Pamela O’Donnell, RN BSN, ED case manager at UHCC. “I read an article about ED overcrowding and ‘frequent fliers’ written by Sheryl Swan, RN, at Swedish Medical Center and then adapted their program to our situation.” says O’Donnell.

To find the sample patient population for the pilot program, the hospital’s information technology department looked at all the ED admissions from the previous six months and compiled a list of the 50 most frequent ED visitors.

“Ideally, we would be able to address each of those top 50 visitors,” O’Donnell says, but instead, the committee of social workers, case managers, and directors decided to deal with a small group and evaluate the program. Based on those results, the committee would decide whether the hospital could take on a larger group.

The committee identified patients with PCPs in the same hospital system. It eliminated patients with sickle-cell anemia, which requires frequent ED visits, and mental health problems, which limit a patient’s ability to comply with healthcare regimens.

After applying those filters, the committee had five patients who met the hospital’s desired criteria:

More than 10 visits to the ED in the past year
Have a PCP at UHCC (previously or currently)
Have no diagnosed psychiatric issues at this time

Those five would be the prospective patients used in the Emergency Department Visit Reduction Pilot Program.

Check out the December 2009 issue of Case Management Monthly to learn more about condition code 44 requirements. You also can discover the benefits of becoming a Case Management Monthly subscriber.

CMW Mentor moment: The ZPICs have begun in Zone 4

Wed, 11 Nov 2009 05:00:00 GMT

The following article is excerpt from HCPro’s newest resource for hospital case managers—www.CaseManagementMentor.com—a free blog dedicated to connecting hospital case managers to industry pacesetters, peers, and best practices.

Health Integrity LLC, the Zone Program Integrity Contractor (ZPIC) for Zone 4 (Colorado, New Mexico, Oklahoma, and Texas) has begun requesting medical records for review.

ZPICs are Medicare audit contractors that specifically identify cases of fraud and abuse. ZPICs may “take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped,” according to the Medicare Program Integrity Manual.

During HCPro’s November 3 audio conference, “Zone Program Integrity Contractors Learn Who They Are, What They Want, and How to Respond to a Review”, a caller from Oklahoma shared that a Health Integrity representative visited the facility recently and stayed for a two-day, on-site audit. During the visit, the auditor reviewed more than 40 medical records related to one-day stays dating back as far as 2007.

This information was not that surprising to Robert Wade, Esq., a partner at Baker and Daniels, LLP, in South Bend, IN. ZPICs have authority to begin reviews as soon as they are awarded a contract. Health Integrity became the Zone 4 contractor during February.

Read the rest of this post, or share your thoughts on this topic.

Browse more blog posts at www.CaseManagementMentor.com.

CMW news: House approves healthcare reform bill

Wed, 11 Nov 2009 05:00:00 GMT

The U.S. House of Representatives recently passed the healthcare reform bill (HR 3962) by a narrow margin (220–215). The bill's estimated cost is more than $1 trillion over the next 10 years.

The Senate is working on its own version of the bill. If that version passes, then a congressional conference committee will meet to compromise on the two versions. If the committee reaches a compromise, it will send that bill would to both the House and Senate for another vote. If it passes both houses, the next step is President Obama’s desk for his signature.

Preliminary drafts of the Senate bill differ from the House version with respect to funding. how many individuals will be covered, and the availability of a public option.

Source: CNN

CMW tip of the week: Strengthen your ED case management program

Wed, 11 Nov 2009 05:00:00 GMT

Consider implementing the following measures to strengthen your ED case management program:

Address problem populations (e.g., frequent ED use). Combining research findings, clinical assessments, and patient preferences builds a solid foundation for developing patient care plans.
Establish a regional ED case management committee. Meet with other case managers in your region regularly to discuss common problems and solutions.
Acquire professional certification. Certification provides a new level of knowledge and skill competencies. It tells colleagues that you meet a national standard of excellence in your field.
Read professional case management publications

This week’s tip was adapted from Emergency Department Case Management: Strategies for Creating and Sustaining a Successful Program published by HCPro. For more information about this book or to order a copy visit the HCMarketplace.

CMW sneak peek: Clearing up condition code 44 confusion

Wed, 11 Nov 2009 05:00:00 GMT

Hospitals must meet certain criteria before they use condition code 44. Consider this example. A patient experiencing chest pain presents to a hospital Saturday night. The hospital does not have weekend case management coverage, so the physician admits the patient as an inpatient. During this time, the physician orders tests, chest x-rays, and other services.

Upon reviewing the case on Monday, the utilization review (UR) committee determines that the patient did not require inpatient admission. Note that the UR committee may never use InterQual or Milliman criteria to deny an admission. Before the hospital can assign condition code 44 and change the patient’s status, it must meet the following requirements:

The change in patient status from inpatient to outpatient is made prior to discharge or release while the beneficiary is still a patient of the hospital
The hospital has not submitted a claim to Medicare for the inpatient admission
A physician concurs with the UR committee’s decision, and his or her approval is documented in the patient’s medical record

If the hospital fulfills these requirements while the patient is still in the building, condition code 44 will allow the hospital to go back and bill all medically necessary Part B services ordered by the physician as if they had been provided in the outpatient setting. The hospital will receive payment via the outpatient prospective payment system. If the hospital cannot fulfill these requirements, it can only bill for Part B diagnostic services.

Check out the November 2009 issue of Case Management Monthly to learn more about condition code 44 requirements. You also can discover the benefits of becoming a Case Management Monthly subscriber.

For even more condition code 44 information, join HCPro December 15 for an audio conference, “Condition Code 44 and the Utilization Review Committee: Ensure Process and Documentation Compliance.” Visit the HCMarketplace to register for this program.

CMW Mentor moment: Possible MIC audit issues that involve case management

Wed, 04 Nov 2009 05:00:00 GMT

There’s no question that audit activity is escalating.

It’s no longer just RAC, MAC, CERT, and ZPIC audits that seek to ensure the accuracy of Medicare payments. Providers are also subject to increased scrutiny on the Medicaid side, as states work with the federal government to help reduce payment error rates and recoup overpayments.

The scrutiny comes in the form of Medicaid Integrity Contractors (MICs) that will begin auditing providers in all states by the end of 2009.

What will MICs audit? It will vary from state to state, of course. James G. Sheehan, the Medicaid Inspector General for New York, listed several issues he anticipates MICs will audit. Sheehan spoke during the October 15 HCPro audio conference, “Medicaid Integrity Contractor Audits: Know What to Expect and How to Prepare.”

Potential MIC audit issues that case management staff members should be aware of includeheart failure and shock. For this issue, MICs will look for failure to meet InterQual criteria for inpatient care.

Read the rest of this post, or share your thoughts on this topic.

Browse more blog posts at www.CaseManagementMentor.com.

CMW news: Nurse association complains about lack of H1N1 respirators

Wed, 04 Nov 2009 05:00:00 GMT

The American Nurses Association (ANA) has written a letter to the Centers for Disease Control and Prevention (CDC) to complain about the shortage of respirator masks, which nurses wear to protect themselves against the H1N1 virus.

The ANA expressed concern about the increasing number of facilities that are reporting a shortage of N-95 respirators. The CDC recommends the N-95 respirators as the minimum level of respiratory protection for healthcare workers who could be exposed to the H1N1 virus.

"Registered nurses want to come to work and do our jobs to take care of patients—we historically have put patients' needs ahead of our own," said ANA President Rebecca M. Patton, RN in an interview with HealthLeaders Media. "So it's absolutely essential to have adequate protection from exposure to the H1N1 virus. If nurses get sick and can't come to work, who will take care of patients?

Source: HealthLeaders Media

CMW tip of the week: Steps to operational discharge planning

Wed, 04 Nov 2009 05:00:00 GMT

Discharge planning applies a process whereby a systematic approach facilitates the transition of patients from one level of care to another, whether within the acute care continuum or beyond. The process includes the following steps:

Begin planning the patient’s entire stay upon admission
Collaberatively determine the patient’s level of care with the interdisciplinary team
Connect patients to the continuing care services they will receive following their stay at your facility
Transition patients to the next level of care

This week’s tip is an excerpt from HCPro book Core Skills for Hospital Case Managers: A Training Toolkit for Effective Outcomes. For more information on this book or to order your copy visit the HCMarketplace.

CMW sneak peek: HINNs help with difficult cases

Wed, 04 Nov 2009 05:00:00 GMT

Patients sometimes refuse to participate in the discharge planning process as a clever way to delay discharge to the next level of care. Michael Schaeffer, LMSW, assistant director of case management/social work at Albany (NY) Medical Center, recalled a patient with a mental health condition who refused to participate and even turned staff members against each other.

“This patient triangulated the attending physician against the unit manager and against the social worker, rallying one excuse followed by another distortion,” said Schaeffer.

Eventually, the facility’s discharge planner, with consent of the attending physician, arranged for the patient to receive dialysis treatment as an outpatient. Upon receiving the requisite Important Message from Medicare (IM), the patient appealed the hospital’s decision. However, while awaiting the Quality Improvement Organization’s (QIO) decision, the patient suddenly became more cooperative. He became more teachable and approachable and agreed to complete his Medicaid application, a task he had previously rejected.

“If anything seems to motivate and inspire people to sit up and listen, it is usually the topic of payment liability,” said Schaeffer.

The QIO ultimately upheld the hospital’s decision, and the patient received an HINN 12. He signed it and left the hospital. The patient returned to the hospital two weeks later with the same complaint, but he was much more cooperative the second time because he knew where he stood pursuant to Medicare rules.

Check out the November 2009 issue of Case Management Monthly to learn other creative ways to reduce LOS. You also can discover the benefits of becoming a Case Management Monthly subscriber.

CMW Mentor moment: Is H1N1 hype clogging your ED?

Wed, 28 Oct 2009 05:00:00 GMT

The nightly news is teeming with stories about seemingly healthy young individuals becoming critically ill from the H1N1 (swine flue) virus, and people are worried.

I am no exception. When I hear a coworker cough or sniffle, I become uneasy. I have been able to remain healthy during this young flu season. However, should I become feverish and start coughing, my unease might escalate to worry. And where do most of us go when our health becomes a concern? Our physician, and if we can’t wait for an appointment, the ED.

EDs are crowded as is. The last thing ED staff members need is people presenting to the ED that are afraid their head cold could kill them. That is why Emory University and Microsoft have teamed up to create the H1N1 (Swine Flu) Response Center.

Read the rest of this post, or share your thoughts on this topic.

Browse more blog posts at www.CaseManagementMentor.com.

CMW news: NY Governor suspends H1N1 vaccine requirement for healthcare professionals

Wed, 28 Oct 2009 05:00:00 GMT

On October 22, New York Governor David Paterson announced that the state no longer will require healthcare professionals in the state to receive the H1N1 vaccine.

Paterson’s decision came after New York nurses objected to the mandate, with some filing lawsuits alleging that the requirement violated their civil rights. However, the announcement fails to mention the vocal opposition. Paterson says he no longer requires the vaccinations because New York will receive less of the vaccine that it had expected.

Paterson still encourages healthcare workers to receive flu shots voluntarily as an infection control measure.

Source: HealthLeaders Media

CMW tip of the week: Early discharge program

Wed, 28 Oct 2009 05:00:00 GMT

An early discharge program can compliment the discharge appointment at the end of the hospital stay. Begin by establishing the desired goal time for morning discharges—hospitals often try for noon. The case manager then works with healthcare providers to complete all discharge requirements, such as physician medication reconciliation, discharge summary, and nursing discharge teaching completion, the day before discharge.

This week’s tip is an excerpt from the Case Management Monthly article “Ask June: What are some creative ways to reduce LOS?” by June Stark, RN, BSN, MEd. For more information on this newsletter visit the HCMarketplace.

Have a tip or tool you’d like to share or maybe a question for our experts? E-mail it to editor Ben Amirault at bamirault@hcpro.com. Your comments or ideas could appear in a future issue of Case Management Weekly.

CMW sneak peek: The RAC effect: How RACs influence case management

Wed, 28 Oct 2009 05:00:00 GMT

By Loretta Sandy, PhD, RN, CCM

One of the primary rules physicians and nurses learn in school is "if it is not documented, it is not done." Another concern expressed by medical professionals in our litigious society is "remember that you may need to defend what you charted in a court of law." Finally, attorneys caution healthcare professionals that the more they chart, the more they may have to defend.

Although these statements are not contradictory, healthcare professionals are typically cautious. However, with the implementation of RAC audits, documentation must be comprehensive because it helps ensure that hospitals receive fair and justifiable reimbursement.

Given the potential effects of a RAC audit, healthcare professionals must understand why they should carefully document the following:

Presenting symptoms
Rationale for a particular level of care
Treatments provided to improve a patient’s clinical status

Healthcare professionals must also substantiate their clinical judgment as to why a patient needs to remain in a given level of care on a daily basis. The case manager should confirm that the documentation is accurate and consistent with the hospital’s level-of-care criteria (e.g., Milliman, Interqual). If clinical documentation is not consistent with screening criteria, it must define the rationale for treatment decisions.

Check out the November 2009 issue of Case Management Monthly to read the other creative ways to reduce LOS. You can also discover the benefits of becoming a Case Management Monthly subscriber.

CMW Mentor moment: Are you paying attention to your case mix index?

Wed, 21 Oct 2009 05:00:00 GMT

This article was written by Loretta Olsen, RN, director of case management at Jennie Edmundson Hospital in Council Bluffs, IA. It is adapted from HCPro’s newest resource for hospital case managers—www.CaseManagementMentor.com—a free blog dedicated to connecting hospital case managers to industry pacesetters, peers, and best practices.

What is case mix index (CMI) and why, as a case manager, do I care?

Financial Management for Nurse Managers and Executives, Third Edition, published by Elsevier, defines CMI as the measurement of the average severity of illness of patients treated by a healthcare institution. CMI helps determine the dollar amount assigned to a diagnosis related group (DRG) for the Medicare population. Medicare assigns a dollar amount, which is partially determined by the CMI, for every facility.

Hospitals use the CMI to create a budget. If the actual CMI is lower than the budgeted CMI, incoming money for those DRGs will be less than expected. This creates an imbalance in hospital revenue. If the money coming in is less than planned, a financial fiasco is possible. Think of CMI as the yellow caution light that warns the hospital of any impending decrease in hospital income. The financial team and senior management monitor the CMI monthly.

Read the rest of this post, or share your thoughts on this topic.

Browse more blog posts at www.CaseManagementMentor.com.

CMW news: H1N1 self-assessment tool could prevent unnecessary emergency department visits

Wed, 21 Oct 2009 05:00:00 GMT

Emory University and Microsoft have teamed up to create a H1N1 self-assessment tool that could help prevent ED overcrowding.

The H1N1 (Swine Flu) Response Center is a Web-based assessment tool that asks site visitors a series of questions, including:

Age
Gender
Geographic location
Severity of symptoms
Length of symptoms

After answering these questions, users receive symptom management advice. In severe cases, the tool instructs users to consult a physician immediately. In less severe scenarios, the tool may instruct users to visit a walk-in clinic or stay in bed and drink fluids.

Site sponsors hope people with less severe symptoms will use this tool to get advice instead of visiting the ED.

Source: HealthLeaders Media

CMW tip of the week: Informing immigration officers about an undocumented alien

Wed, 21 Oct 2009 05:00:00 GMT

This week’s tip is an excerpt from the Q&A portion of the HCPro audio conference Caring for Uninsured and Undocumented Patients: Safe and Cost-Effective Discharge Solutions. Matt Boettcher, LCSW, director of case management at St. Joseph’s Hospital and Medical Center in Phoenix, answered this question.

Q: Are hospitals required to inform immigration officials when undocumented aliens seek care?

A: There actually are federal public health laws that indicate that hospitals and healthcare entities are exempt from reporting requirements. When you think about it, it makes a certain amount of sense for the larger healthcare concerns of the community. With things like tuberculosis, if people thought they were going to be reported, they wouldn’t seek treatment.

CMW sneak peek: What are some creative ways to reduce LOS?

Wed, 21 Oct 2009 05:00:00 GMT

by June Stark, RN, BSN, MEd

Strategic innovations for reducing length of stay (LOS) that have emerged in recent years provide a wide range of choices for case managers.

Many innovations have become predictors of success and may enhance hospital throughput from the ED door to discharge. These initiatives also cross the entire healthcare continuum, providing case managers with the opportunity to select initiatives that have a focused effect on LOS.

I’ve listed many of these initiatives in chronological order, from the beginning of the hospital-based continuum to the conclusion of the stay:

Institute preoperative admission screening for all elective surgeries to decrease LOS. Positioned on the front end, the case manager meets the patient and/or family and sets hospital expectations along with preadmission discharge planning.

At the time of admission, a unit-based case manager assignment model is more reliable for reducing LOS when compared to specialty case manager assignment. The advantage of unit-based case management is that the case manager is present to ensure completion of all discharges. Specialty-based case managers often follow a physician group’s patients from one unit to another. A case manager’s travel time can average approximately 90 minutes, according to published reports.