Case Management and The Revenue

Cycle

AAHAMThursday, May 14,

2009

Purpose of this Case Study

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?

FINANCIALCOUNSELING

INSURANCE VERIFICATION

PRE-REG & PRE-CERT

SCHEDULING

REGISTRATION& POS CASH

COLLECTIONS

CHARGECAPTURE& ENTRY

MEDICAL MANAGEMENT

MEDICALRECORD &

CODINGCLAIMS

SUBMISSION

THIRD PARTYFOLLOW-UP

PAYMENT POSTING

REJECTIONPROCESSING

DENIAL &APPEAL

MANAGEMENTCONTRACTMANAGEMENT

EDI-capability

FOCUS AREA

RegulatoryCompliance

Metrics & KPIsCDM

Assessment

Conducted over 4 to 6 days, consisting of: Interviews

What have you inherited that may not belong in your department?

Observations Chart review Data Analysis

Departments involved in interviews Registration/Patient Access Case Management Social Work Utilization Management Denials Management Observation Unit Health Information Management

Overview

RegistrationFindings 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 ManagementFindings Medicaid denials are appealed by an LPN in case

management All other denials are reviewed in the business office by non-

clinical 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 ReviewFindings 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 ManagementFindings (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 ManagersFindings 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 WorkersFindings 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 ModelsRoles: People

3:3 Model 2:1 Model 3:1 Model

1. Social Workers (SW)• Discharge Planners• Psychosocial Needs

2. Utilization Management (UM)

• RN• Insurance Management• Other

3. Case Managers (CM)• Nurses• Models within

CM assignment varies• Unit• Physician • Payer• Disease Management

Two versions1. UM/CM (2) with SW

on own2. CM/SW (2) with UM

on own

CM assignment varied as in 3:3• Unit• Physician • Payer• Disease Management

CM/UM/SW roles in one person

Assignments• Unit• Physician • Payer• Disease

Management

Model ComparisonModel

Advantages Disadvantages

3:3 Individual ExpertiseEasiest to implement

3 people in chartPoor productivityConfusing to customers Confusing to patientsDifficult case sharingHand-off mishapsMore staff to manage

2:1 Works well in certain hospitalsExpertise drivenPromotes teamworkGood transition to 3:1

2 people in chartConfusing to customersDifficult case sharingHand-off mishaps

3:1 1 person in chartClear assignment for customersComplete start to finish careFewer staff to manageComprehensive understanding of all aspects has positive revenue implications

Only for high-functioning hospitalsRequires more training than others

Choosing the Right Model

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 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 WorkRecommendations Move entire Case Management department to the CFO Weekly revenue cycle meetings

Registration/Patient Access Supervisor Registration/BO Director CM Director HIM Director Coding Supervisor Charge Master leader Director Revenue Cycle Representative negotiating managed care contracts CFO

RecommendationsImplement weekly “long” stay/high dollar meeting

Goal: review patients with LOS>5 days; charges higher than $50,000; and all self-pay patients

Attendees Case Managers/Social Workers/Utilization Review staff Patient Access HIM/ coding Physician – hospitalist group Physician advisor or CMO Nursing Financial counselor

Meeting Process

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

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 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

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 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

IQ books Software purchased from McKesson 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 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

1. Pre-admission review (Acute)

2. Admission review (Acute or Observation)

3. Continued stay review (Acute or Observation) Cannot go backwards (e.g., acute back to

observation)

4. 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

Performed when IS not met or on discharge Clinical disagreement arises

Supervisor-level review Attending physician conversation Physician Advisor

Patient refuses to discharge Physician support Hospital Inpatient Notification of Non-

payment

Observation ProcessFindings Observation versus Inpatient status determined by

physician recommendation upon admission – UM review for clinical support of their decision

Presence of the order is checked after discharge unless CM happens to be reviewing the chart

If the order is unclear or missing, CM calls the physician for a clarification order

Continued stay reviews are completed but not retained in the patient record

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 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 Two or more FTEs to cover at least 12 hours a day, 7

days a week RNs preferred, with previous Utilization Review

Experience Laptop needed for mobility around hospital

Observation Responsibilities

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 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 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.