ED gatekeepers essential to financial health
CMs maximize reimbursement
A robust emergency department case management program is becoming essential as hospitals struggling with capacity and payer sources clamp down on inappropriate admissions, says Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY.
"Hospitals need case managers in the emergency department to stop inappropriate admissions. There is no value in admitting a patient and exposing him to the hospital environment and not getting paid for it," she says.
Cesta advocates putting case managers and social workers in the emergency department for a minimum of eight to 12 hours a day to review every single admission for medical necessity and admission status. They need to be dedicated to the department full time and not just be on call or float through the ED, Cesta says.
"A few hospitals have case managers in the ED 24-7, but that may not be necessary. I advocate for 16-hour coverage during the week and absolutely on the weekends when so many inappropriate admissions sneak in," she says.
Simply having a case manager review all admissions from the emergency department can have a major effect on the bottom line, adds Joanna Malcolm, RN, CCM, BSN, senior consultant for Pershing, Yoakley & Associates in Atlanta.
Many times the case management department simply does not have the staff to place someone full-time in the emergency department, she says.
"But this is a situation where hospitals can't afford not to have a gatekeeper in the emergency department, even if it's just for one shift," Malcolm adds.
An emergency department case manager can ensure that patients who aren't appropriate for inpatient care get treatment in the emergency department and are discharged to home, rather than being admitted, she reports.
"People have had the idea that if you keep patients out of the hospital, the hospital will lose revenue. But if patients are admitted inappropriately, the payers won't pay and the Recovery Audit Contractors are going to take it back," she says.
The problem is compounded by the fact that some hospitals contract for the services of emergency department physicians, and often the contract is based on the expected number of admissions, points out Brenda Keeling, RN, CPHQ, CPUR, of Patient Response, a Milburn, OK, health care consulting firm.
"Procedures that once were appropriate admissions are now performed in the outpatient setting. This should result in reduced admissions and an increase in outpatient services, but for some emergency room physicians, the game plan increases admissions if possible," she says.
The hospital is unlikely to be reimbursed if patients are admitted for conditions such as chest pain, medical back pain, and interventional cardiology procedure, Malcolm points out.
"There are many disease processes that can be handled in the emergency department, rather than admitting the patients," she says.
For instance, patients with congestive heart failure may be able to go back home instead of being admitted for several days if they are given Lasix and oxygen and kept until their condition stabilizes, Malcolm says.
"If hospitals do not have a sufficient census to put a full-time case manager in the emergency department, they should develop a process where a case manager reviews the records prior to a level-of-care determination," Keeling says.
Have someone from your case management staff visit the emergency department every few hours and review the records to make certain that patients meet admission criteria, she says.
An alternative would be to take one case manager out of the floor mix and give him or her the responsibility of reviewing all admissions that come in that day and the night before, Malcolm says.
Direct admissions is another area that needs close scrutiny because it's where a lot of inappropriate admissions slip in, Keeling says.
"Most hospitals don't look at direct admits, but they need to scrutinize them as carefully as other admissions," she adds.
Friday afternoon is a common day for soft admissions, Keeling says.
For instance, a patient may need dialysis on Saturday but the dialysis clinic is closed; so, the patient may be admitted with a vague diagnosis so he can receive his dialysis on Saturday.
Make sure that your case managers do more than just validate that the patient's admission meets acute care criteria, Keeling recommends.
"In the past, case managers could focus on substantiating the DRG, but now they need to make sure there is a level-of-care order and that the chart includes the clinical documentation to substantiate the level of care," she adds.
A robust emergency department case management program is becoming essential as hospitals struggling with capacity and payer sources clamp down on inappropriate admissions, says Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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