Transcript Slide 1

Case Management and
The Revenue Cycle
AAHAM
Thursday, May 14, 2009
Purpose of this Case Study
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An assessment was performed to identify opportunities
for improvement in the Revenue Cycle, focusing on
case management.
Findings and recommendations address areas of
improvement that could impact revenue capture,
compliance, and reduce RAC denials.
What is Revenue Cycle?
MEDICAL
CHARGE
CAPTURE
& ENTRY
MANAGEMENT
MEDICAL
RECORD &
CODING
CLAIMS
SUBMISSION
REGISTRATION
& POS CASH
COLLECTIONS
THIRD PARTY
FOLLOW-UP
CDM
Metrics & KPIs
FOCUS AREA
FINANCIAL
COUNSELING
Regulatory
Compliance
EDI-capability
PAYMENT
POSTING
REJECTION
PROCESSING
INSURANCE
VERIFICATION
PRE-REG &
PRE-CERT
CONTRACT
SCHEDULING
MANAGEMENT
DENIAL &
APPEAL
MANAGEMENT
Assessment
Conducted over 4 to 6 days, consisting of:
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Interviews
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What have you inherited that may not belong in your
department?
Observations
Chart review
Data Analysis
Overview
Departments involved in interviews
 Registration/Patient Access
 Case Management
 Social Work
 Utilization Management
 Denials Management
 Observation Unit
 Health Information Management
Registration
Findings
 Staff require orders prior to procedures
 Staff do not always ask to see insurance cards and identification
 Inefficient communication between patient access and utilization
Recommendations
 Implement a quality audit for registration and insurance verification
 Involve patient access in the weekly case management meetings to
address authorization issues
 Patient access and utilization review staff need to consistently utilize
work lists provided by the system to ensure information is shared
between departments
Denial Management
Findings
 Medicaid denials are appealed by an LPN in case management
 All other denials are reviewed in the business office by nonclinical staff
Recommendations
 All denials reviewed by same area, reporting to patient access
 All clinical denials reviewed by a nurse
 Enhance denial tracking by using a common work list with all
denials in process and capturing denial reasons to uncover trends
Utilization Review
Findings
 UR staff each have their own daily work flow; however, the
process is similar enough to allow staff to cover for each other
 Process is paper driven and requires a number of manual steps
 UR staff do not use the provided system for work lists
Recommendations
 Define work flow and processes
 Evaluate staffing plan to promote teamwork with CM
 Provide feedback on denial trends to UR staff
Case Management
Findings
 Documentation process is inconsistent for case management, and
forms are ineffective
 Documentation does not always stay with the patient’s chart
 There is no defined or consistent work flow process
 Staff lack tools required for their jobs: text pagers/cell phones,
printers, fax machines
 The Important Message from Medicare and Choice letters are not
provided to patients on a consistent basis
Case Management
Findings (continued)
 No formal discharge rounds or long-stay patient meetings
currently being conducted
 Tasks are assigned by discipline (SW versus RN), which creates
confusion for patients, hospital staff, and amongst themselves
 No physician advisor/champion to support the department in
difficult physician situations or to appeal denials
 Nursing home referral process is disjointed, involving various
departments
Case Managers
Findings
 Case Managers lack a consistent daily work flow
 Most try to see Observation patients first
 Reactive versus proactive
 Case Manager carrying 30-50 patients a day
 Limited direct communication with physicians
 Limited insight into financial impact of case management
Social Workers
Findings
 Social workers receive unnecessary referrals as a result of limited
patient screening performed by nursing staff
 Confusion regarding which tasks require a social worker and
which belong to case managers
 Social workers spend a significant amount of their time on
nursing home placements
Case Management Models
Roles: People
3:3 Model
2:1 Model
1. Social Workers (SW)
Two versions
• Discharge Planners
• Psychosocial Needs
3:1 Model
CM/UM/SW roles in one
1. UM/CM (2) with SW on own person
2. CM/SW (2) with UM on own
2. Utilization Management (UM)
• RN
• Insurance Management
• Other
3. Case Managers (CM)
• Nurses
• Models within
CM assignment varies
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Unit
Physician
Payer
Disease Management
CM assignment varied as in 3:3
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Unit
Physician
Payer
Disease Management
Assignments
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Unit
Physician
Payer
Disease Management
Model Comparison
Model
Advantages
Disadvantages
3:3
Individual Expertise
Easiest to implement
3 people in chart
Poor productivity
Confusing to customers
Confusing to patients
Difficult case sharing
Hand-off mishaps
More staff to manage
2:1
Works well in certain hospitals
Expertise driven
Promotes teamwork
Good transition to 3:1
2 people in chart
Confusing to customers
Difficult case sharing
Hand-off mishaps
3:1
1 person in chart
Clear assignment for customers
Complete start to finish care
Fewer staff to manage
Comprehensive understanding of all aspects has
positive revenue implications
Only for high-functioning hospitals
Requires more training than others
Choosing the Right Model
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FTEs will depend on hospital services
Denial resolution falls with front or back end regardless of
model utilized
Caseloads
 3:3
40-50s
 3:1
22-25
Hospital culture
Compliant and revenue-conscience
Recommendations
New staffing model
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Caseloads 22-25 based on floor assignment
2-in-1 model
Nursing home placement coordinator
Gatekeeper 24/7
Cross training is key to success
New orientation plan
Case Manager/Social Work
Recommendations
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Move entire Case Management department to the CFO
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Weekly revenue cycle meetings
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Registration/Patient Access Supervisor
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Registration/BO Director
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CM Director
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HIM Director
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Coding Supervisor
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Charge Master leader
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Director Revenue Cycle
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Representative negotiating managed care contracts
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CFO
Recommendations
Implement weekly “long” stay/high dollar meeting
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Goal: review patients with LOS>5 days; charges higher than $50,000; and
all self-pay patients
Attendees
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Case Managers/Social Workers/Utilization Review staff
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Patient Access
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HIM/ coding
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Physician – hospitalist group
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Physician advisor or CMO
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Nursing
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Financial counselor
Meeting Process
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Distribute list 24 hours ahead of meeting
Schedule for each Case Manager (e.g., 3-3:10 Mary)
Script expectations
 Basic clinical, Days authorized, Days left for Medicare,
Discharge plan, Problems
 Physician issues
 Compliments to be shared
Follow-up on compliments
Sample Patient Report
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Patient Jon Doe admitted 7 days ago for sudden onset confusion
My discharge plan is…
I faxed clinicals yesterday and have 3 more days authorized
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Report for tracking: Supervisor works it that AM and knows who
is behind
Dr. Smith seems to be dragging out the stay
No family support
I’d like to thank the PT that saw him yesterday, she was very
patient (specifics)
Tools Implemented
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Defined work flow and updated policies and procedures
Improved documentation with customized forms to assess risk
and plan for placement
Defined which case management documents become a
permanent part of the chart and are scanned promptly
Provided tools like cell phones and laptops with wireless access
Trained staff to use Interqual criteria to document medical
necessity
InterQual
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InterQual (IQ) criteria is a trademarked tool provided by
McKesson Health Solutions
IQ is the preferred tool used by the Centers for Medicare and
Medicaid Services and most RAC audits
CMS requires hospitals to monitor and document medical
necessity to assure compliance
Methods
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IQ books
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Software purchased from McKesson
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Case Management software that includes IQ within its product
Level of Care Definitions
Category or setting based on the clinical picture when patient is admitted to the
hospital and/or when patient reaches clinical stability at one level.
1.
Observation: onset last 24 hours, reasonable expectation that duration of
assessment is 6-24 hours, assessment/medications unresponsive for at least 4 hours
ER treatment, psychiatric crisis intervention
2.
Acute: onset within one week, medications requiring monitoring q4-8 hours, IV
medications, post critical care, post vent wean
3.
Intermediate: onset within last 24 hours, medications requiring monitoring at least
2-4 hours, hemodynamically stable, telemetry, neuro assessment, post-op trauma
4.
Critical: reasonable expectation for patient to stabilize with high-tech critical care,
hemodynamically unstable, medication monitoring q1-2 hours, acute intubation, etc
5.
Levels continue with LTAC, Acute rehab, sub-acute rehab, SNF, Home Care, home
Definitions
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Severity of Illness (SI) criteria consists of objective, clinical
indicators of illness including chronic illness or co-morbidities,
which focus on an individual patient’s clinical presentation rather
than the diagnosis
Intensity of Service (IS) criteria consists of monitoring and
therapeutic services, singularly or in combination, that can only be
administered at a specific level of care
Discharge Screens (DS) are organized by the levels of care subsets
and provide objective, clinical indicators to determine if the
patient has reached the level of clinical stability appropriate for a
safe transfer to a different level of care
Review Process
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4.
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Pre-admission review (Acute)
Admission review (Acute or Observation)
Continued stay review (Acute or Observation)
 Cannot go backwards (e.g., acute back to observation)
Discharge review
Gatekeeper or case manager to perform IQ reviews
Always start with acute care section to see if criteria is met
Observation status should be used if case does not meet acute
criteria
Discharge Review
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Performed when IS not met or on discharge
Clinical disagreement arises
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Supervisor-level review
Attending physician conversation
Physician Advisor
Patient refuses to discharge
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Physician support
Hospital Inpatient Notification of Non-payment
Observation Process
Findings
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Observation versus Inpatient status determined by physician
recommendation upon admission – UM review for clinical support of
their decision
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Presence of the order is checked after discharge unless CM happens to
be reviewing the chart
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If the order is unclear or missing, CM calls the physician for a
clarification order
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Continued stay reviews are completed but not retained in the patient
record
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Poorly understood process by all involved
Observation Process
Recommendations
 Implement 24/7 gatekeeper role to recommend status on all
patients entering the hospital at all access points
 Order present
 Charges entered
 Case managed
 Change billing to hourly
Gatekeeper Role: Overview
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Responsible for patients needing a bed: inpatient, observation,
ED, L&D, etc.
Ensures that a status order is in all records
First to know of requests for beds to allow for immediate
assessment of status, then calls House Supervisor
Logistics
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Two or more FTEs to cover at least 12 hours a day, 7 days a week
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RNs preferred, with previous Utilization Review Experience
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Laptop needed for mobility around hospital
Observation Responsibilities
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Entering OBS hours with appropriate start and stop times
Run OBS list twice a day
 Visit floor to assess OBS patient progress toward
discharge
 Perform usual CM tasks to manage these patients,
including discharge planning
 Upon discharge or conversion to inpatient, enter order
and enter exact observation hours into system
Results
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Improved compliance, with an appropriate level of care
assigned within 24 hours of admission and with a
corresponding order present in the chart
Improved revenue capture due to proper procedures in
place at beginning of patient stay
Reduced LOS with proactive planning for discharge and
interdepartmental meetings on long stay/high dollar cases
Reduced RAC denials
Impact on RAC Audit
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Using InterQual criteria to determined the correct level of care
will establish medical necessity and ensure that an appropriate
order is in the chart within 24 hours of admission.
Assigning an appropriate patient status prevents one day
inpatient stays, which have been targeted for RAC.
Continued stay reviews ensure that a patient meets the Intensity
of Service requirement and are performed every three days to
prevent an unnecessarily extended length of stay.
If there is no documentation in the chart to support the level of
care chosen by the physician, these continued stay reviews may
prompt improved clinical documentation.