Extra diagnostic testing can cost hospitals big
Pay close attention to patients' resource utilization
Hospitals are losing large amounts of money on extra and inappropriate diagnostic testing and procedures, as well as outpatient procedures performed in the inpatient setting because third-party payers frequently are denying the claims, says Brenda Keeling, RN, CPHQ, CPUR, of Patient Response, a Milburn, OK, health care consulting firm.
"Case managers should be on the lookout for unnecessary resource utilization because their hospitals aren't going to get paid for it. If they see something in the chart that might be questionable, they should query the physicians about it," she says.
"Often patients come in with one acute care diagnosis and the physician orders diagnostic testing for other complaints that have no correlation to the acute care condition that prompted the admission," Keeling says.
For instance, a patient may come in with pneumonia and complain of having back pain for six months, so the doctor orders an MRI. The chronic back pain has nothing to do with the acute reason the patient is hospitalized, so the hospital is utilizing expensive resources for which there will be no additional reimbursement, she adds.
MRIs of the extremities or the spine for chronic pain rarely can be justified in the acute care setting unless the patient was recently injured, Keeling says.
Another example would be a patient who comes to the emergency department with a possible gastrointestinal bleed, is hospitalized, and receives an esophagogastroduodenoscopy (EGD).
"If the patient is asymptomatic, has a stable hemoglobin and a stable hematocrit, and isn't throwing up or passing bright-red blood, an inpatient EGD may be questioned by the payers and may not be reimbursed. According to Medicare, once the patient is stable, he or she can be worked up on an outpatient basis," Keeling says.
Other times, doctors will order the same test on subsequent days when the results of the first test are within the normal limits and the patient is asymptomatic, such as ordering a complete blood count several days in a row for patients hospitalized with GI bleeding, Keeling adds.
Case managers should review the charts of all patients daily, regardless of payer source, and make sure that the procedures the doctor orders are necessary for the condition for which the patient is hospitalized, suggests Joanna Malcolm, RN, CCM, BSN, senior consultant for Pershing, Yoakley & Associates in Atlanta.
For instance, ask the physician if the colonoscopy or the mammogram is really necessary on an inpatient basis or if the patient could get it as an outpatient.
Make sure your staff stagger their hours so someone will be on duty when the physicians make rounds and can query them in person, Malcolm adds.
Make sure that laboratory tests and X-rays and the reports in the chart are done in a timely manner, she suggests.
"I'm not suggesting that case managers take over the unit secretary's job, but if they notice something is missing, they should communicate that it needs to be there. Otherwise, when the physician makes rounds, if something isn't in the chart, he or she will likely postpone the discharge until the next day," Malcolm says.
Hospitals are losing large amounts of money on extra and inappropriate diagnostic testing and procedures, as well as outpatient procedures performed in the inpatient setting because third-party payers frequently are denying the claims, says Brenda Keeling, RN, CPHQ, CPUR, of Patient Response, a Milburn, OK, health care consulting firm.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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