HCPro.com - Case Management - DO NOT USE Top Stories

‘Making case management history’ one story at a time

Tue, 01 Dec 2009 18:26:00 GMT

Because case managers have such an intimate knowledge of the healthcare system, they are certainly qualified to comment on what works and what doesn’t. That is why the CMSA Public Policy Committee is doing its part to shape healthcare reform.

Traveling exposes case manager to many models

Tue, 01 Dec 2009 18:20:00 GMT

Travel nursing is ideal for healthcare professionals who want to explore the country while continuing their careers and gaining valuable experience.

Pilot program identifies the cause of frequent ED visits; patients overcome barriers

Tue, 01 Dec 2009 18:17:00 GMT

For many facilities the emergency department (ED) is a chaotic and crowded place.
Making things worse, there is a population of patients that use the emergency department as their main access point to healthcare.

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

Could RAC mass adjustment changes mean increase in automatic audits?

Thu, 12 Nov 2009 05:00:00 GMT

Providers who believe their RAC denials will be limited to 200 every 45 days (corresponding with the medical record request limits) may be in for a surprise. Those limits apply only to complex audits, but no such limits exist for the number of automatic reviews RACs can perform.

“RACs can do as many [automated reviews] as they want. I think it is in people’s heads that they can look at only 200 at any one time, but that’s really not true,” says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.

In fact, recent changes to the RAC process for handling mass quantities of recoupments from automatic reviews may even make it easier for RACs to increase their auditing capabilities—meaning the potential for even more denials for providers.

In the past few weeks CMS released three transmittals (R561OTN, R571OTN and R573OTN) detailing several technical changes to “enhance” the RAC mass adjustment process. Essentially, the changes improve the process for the RACs by automating what used to be much more labor-intensive process of initiating mass adjustments of similar claim and/or service types.

“CMS is going to allow RACs to now upload entire files to the intermediary to make mass adjustments, and this is going to make automated denials much quicker for RACs,”

Hoy says. “And whenever you go from manual to automated, you’re going to have a huge increase in efficiency. The changes mean a hospital could get literally thousands of claims denied in one day.”

CMS first came out with a RAC-oriented mass adjustment process in 2007, but the changes should make it easier for the RACs. “Basically they can just run reports now,” Hoy explains.

And if the back-end work involved in processing mass quantities of automatic denials decreases for the RACs, does it mean an increase in their ability to further audit healthcare providers?

We may have to wait until April 5, 2010, when the changes take effect, to find out.

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 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

The RAC effect: How RACs influence case management

Sun, 01 Nov 2009 14:35:00 GMT

One of the major challenges for hospitals today is the Recovery Audit Contractor (RAC) program. Case managers should play an essential role in ensuring that their institutions accurately adhere to evidence-based practice and understand the documentation elements necessary to support the level of care and treatment provided.

HINNs help with difficult cases

Sun, 01 Nov 2009 14:30:00 GMT

The HINN and the Important Message from Medicare (IM) are useful tools in the case manager’s arsenal. Case managers can use both documents during difficult cases to encourage uncooperative patients to participate in the discharge planning process and educate patients about their rights, liability, and options.

Clearing up condition code 44 confusion

Sun, 01 Nov 2009 14:28:00 GMT

Case managers struggle with the condition code 44 requirements. Our experts address the most common misconceptions and clarify the fuzzy areas.

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

Boston man to serve 10 years in prison for several counts of healthcare and insurance fraud

Wed, 21 Oct 2009 05:00:00 GMT

Former health clinics owner, Tu Quy Mai, will serve 10 years in prison for committing several acts of mail fraud and submitting false claims, according to a Department of Justice release. Mai, 59, pled guilty on December 10, 2008 and will pay over $3.7 million in restitution and a $5,400 special assessment.

Mai established and operated several clinics around the Boston area where he would submit false and fraudulent medical and physical therapy billing claims for staged auto accidents. Mai would pay people to stage accidents, while ordering workers to prepare false records, including evaluation reports and notes of alleged treatments for the “injured,” when neither were performed.

From 2000 through 2006, Mai often changed the name of his clinics and billing companies and told other coworkers to maintain themselves as owners. During that time, insurance companies paid more than $4 million in claims submitted by Mai’s clinics and billing companies.

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 news: Another Medicaid reduction possible when stimulus funds are gone

Wed, 14 Oct 2009 05:00:00 GMT

The decline in tax revenue and increase in Medicaid enrollment combined to put the squeeze on the Medicaid budget for many states.

As a result, 13 states will reduce Medicaid pay for physicians in fiscal year 2010. They include: Georgia, Louisiana, Minnesota, North Carolina, Vermont, Wyoming, California, Utah, Washington, Colorado, Hawaii, Maryland, and Ohio..

In fiscal year 2009, Medicaid enrollment grew by 5.4% and total program spending increased by 7.9%, the fastest pace in five years. Without the federal stimulus bill, the current economic climate would have forced states to cut Medicaid funding even more drastically. That additional federal funding for Medicaid runs out December 31, 2010. This has Medicaid directors worried about cuts that may be in store for fiscal year 2011.

Source: American Medical Association

CMW mentor moment: Identifying emergency department 'regulars' can improve throughput

Wed, 07 Oct 2009 05:00:00 GMT

The following article by Pamela O'Donnell, an emergency department case manager at University Hospital, Upstate Medical Center, in Syracuse, NY. 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.

It’s safe to say that every emergency department (ED) sees its fair share of “frequent fliers”—patients who seem to use the ED instead of other healthcare resources in the community. Knowing the players, specifically the ED clientele, can help an ED case manager address issues that affect throughput.

In the past year, the case management team at University Hospital, Upstate Medical Center in Syracuse, NY established a pilot program, modeled on programs in other hospitals. The hospital generated a list of ED frequent fliers during the previous six-month period. We identified a group of patients who frequent the ED and have primary care providers within the same hospital system. Using a team approach, case managers and outpatient social workers worked to address barriers in the patients’ lives that may cause them to use the ED instead of their primary care physicians.

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

Browse more blog posts at www.CaseManagementMentor.com.

CMW news: Incomplete discharge summaries to blame for preventable errors

Wed, 23 Sep 2009 05:00:00 GMT

A study released by the Indiana University School of Medicine finds that hospital discharge summaries lack information important to patients’ continuity of care.

Indiana University School of Medicine researchers published their findings in the September issue of Journal of General Internal Medicine under the title Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending Results and Outpatient Follow-up Providers.

The researchers reviewed 668 discharge summaries from two academic medical centers. They found that the hospitals discharged nearly 41% of the patients with test results pending—9% of those tests required changes with respect to patient care. However, the hospitals documented only 16% of those tests in patient discharge summaries. Only 13% of summaries included all pending tests.

Researchers say without that information, primary care physicians can’t provide the appropriate care patients need after discharge.

“Errors in communication reportedly contribute to over half of all preventable adverse events and are associated with twice as many deaths when compared with errors due to clinical inadequacy,” researchers conclude in their report.

Source: American Academy of Professional Coders and American Medical Association

CMW Mentor moment: One bad run-in shouldn't define case management field

Wed, 16 Sep 2009 05:00:00 GMT

The following article is a letter to the editor that Nancy Sullivan, director of case management at Massachusetts General Hospital in Boston, submitted to The Boston Globe. The full letter can be read at 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.

In her op-ed “The ‘quicker and sicker’ exit strategy” dated July 30, Deborah Schuss describes her family’s negative—and indeed, unacceptable—encounter with a case manager. One patient’s bad experience, however, should not define an entire field.

As trained and experienced nurses, social workers, and other health professionals, case managers work diligently and compassionately to ensure a safe transition for patients from the hospital to the next setting of care or home. Case managers serve as trusted guides during a period of uncertainty and change, helping families sort out details of ongoing care, and arranging for services after discharge.

As essential members of the patient care team, case managers advocate for the patient and family as they collaborate with physicians, nurses, and others. And while case managers help ensure that care is delivered in a timely and cost-effective manner, their decisions are driven by what is in the patient’s best interest.

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

Browse more blog posts at www.CaseManagementMentor.com.

CMW tip of the week: Billing for injections and infusions using condition code 44

Wed, 02 Sep 2009 05:00:00 GMT

This week’s tip, an “Ask the Expert,” was answered by Judith Kares, JD, CPC, a regulatory specialist for HCPro, Inc.

Q. My understanding of the condition code 44 process is that we technically don’t have an order for observation until the actual observation order written. Does this mean that we may not charge for all the infusions and injections administered while the patient’s status was incorrectly inpatient?

A. No. My understanding is as follows. When you are able to successfully change the patient's status from inpatient to outpatient, using condition code 44, services provided in the inpatient setting are covered and payable on the same terms and conditions as if they had been provided in the outpatient setting. Because the hospital did not meet the observation order requirement, however, it may not convert that period of inpatient care to observation. Therefore, there should be no separate line item reported on the subsequent outpatient claim for observation services. All of the ancillary services, however, would generally be billable, subject to outpatient coverage and payment provisions.

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

CMW news: Patient deportation case highlights issues with illegal alien healthcare

Wed, 26 Aug 2009 21:22:00 GMT

A medical ethicist says people who are angry at a South Florida hospital for repatriating a brain-damaged patient to his native Guatemala should instead push Congress to expand emergency healthcare coverage to illegal aliens.

Arthur Caplan, a professor of bioethics at the University of Pennsylvania Center for Bioethics, says Martin Memorial Medical Center was unfairly criticized after the Stuart, FL hospital chartered an airplane and returned Luis Jimenez, 37, to his native Guatemala in 2003. The hospital had been providing unreimbursed long-term care for the uninsured day laborer ever since he suffered severe head injuries in a 2000 automobile accident that left him partially paralyzed. The hospital placed the value of the uncompensated care at around $1.5 million.

"Those who are outraged over sending him home should try to push for illegal aliens to be covered. Good luck with that," Caplan says. "You can yell at the hospital all you want, but if he was in a public plan they probably would have kept him here because he would have had coverage. In a way, each one of us decided to send him home."

Source: HealthLeaders Media