Technologies save case managers time and money
Discharge tracking, pre-certification addressed
Case managers struggling with everything from pre-certification to tracking patient discharges should take note of several expanding technologies that could help save considerable amounts of time and money.
VoiCert software
One technology now employed by more than 100 hospitals in 10 states is a new voice-based product that automates and records the pre-certification process for hospital stays, including both inpatient and outpatient procedures.
The VoiCert software, developed by The White Stone Group in Knoxville, TN, lets nurses dial in from any telephone and submit demographic and clinical information to the system and then return to work as VoiCert calls the insurance company and waits on hold to secure authorization. That authorization then is delivered to the nurse and permanently stored.
Pamela Bassler, RN, MPH, utilization manager at Erlanger Medical Center in Chattanooga, TN, reports that since her 11 utilization managers started using VoiCert earlier this year, the percentage of denials at discharge has been reduced from 6% to 1.8%.
Bassler estimates that she is able to save nearly 40 hours of staff time each week in addition to the money saved on overturned denials.
The value of VoiCert to a hospital is threefold, says Blair Wright, director of strategic marketing at White Stone.
First, it saves the hospital time. Hospitals not only have to worry about pre-certification but concurrent review authorizations, verification of authorization numbers, and other administrative tasks. "Hospital staff spend a lot of time on hold with insurance companies trying to get information," he says.
While the average phone call to an insurance company can easily take a half an hour, it only takes two to three minutes for nurses to submit that information to VoiCert.
Second, VoiCert saves money, Wright says. That’s because the system records the entire voice transaction of what the hospital submits to the insurance company and, in turn, the insurance company’s response. "That can be retrieved at any point for documentation purposes," he explains. "It is very effective at overturning denials and avoiding the appeals process."
Third, VoiCert can improve relationships with physicians, Wright says. "This is critical because physicians are responsible for pre-certification for outpatient procedures or a scheduled admission," he says. "Doctors have to go through the same lengthy procedure that hospitals must go through."
VoiCert allows physicians to call a hospital upon a patient’s admission and submit the information required by the insurance company. The program then sends the response to the physician and copies the hospital. Physicians save time as well as money because they are not charged, Wright notes.
According to Wright, a VoiCert system can pay for itself in six to nine months. "We perform cost justification as a part of our presentation using their activity level," he explains. Wright’s group also asks hospitals for information on their denied claims as part of that process.
The Clinical Client
New technologies and techniques also are emerging to assist in the patient discharge process. One new technology designed for case managers is the Clinical Client, developed by Axiom Internet Commerce in Canoga Park, CA, which provides interdisciplinary clinical record keeping for managing patient care. Compilations of patient demographics are available for inpatient or outpatient use.
"What we are doing is basically linking hospital discharge planning more tightly with the doctor and the follow-up services," says Jim Bullough-Latsch, chief technology officer at Axiom.
"We have expanded the discharge order from just being the signal to discharge the patient, to supporting protocols for follow-up care to include home care and other services," he says.
The benefits to acute care facilities include improved management of length-of-stay compliance as well as reduced unplanned readmissions. The benefits to home health care include pre-signed physician orders for start of care, and start of care within two hours of hospital discharge, Bullough-Latsch says.
The Clinical Client originally was designed for case managers in home health, he says. Then an inpatient case manager and hospice case manager were added. Now a discharge planning case manager is included, as well as additional features to support the other disciplines.
"It really always has been designed for case management," Bullough-Latsch says. "The new feature this year addresses protocols and scheduling for the hospital discharge planner."
Could help with HIPAA compliance
While this program was not designed specifically to help case managers and others comply with the Health Insurance Portability and Accountability Act (HIPAA), it may prove very useful in that regard, Bullough-Latsch argues.
He warns that case managers no longer will be able to do everything on paper once HIPAA is implemented. "HIPAA will hit case management hard. At that point, you will have to have a written process, and you have to be able to track all the information that you disclose."
"HIPAA says that if you are managing a case, the information you are giving out has to be controlled and you have to keep track of who you give it to," he explains. "That basically means you can’t use the telephone without some follow-up paperwork."
Many case managers currently use systems developed for something else because it is very hard to do case management with just one system, Bullough-Latsch notes. The Clinical Client can be used as a stand-alone software package for a single user or as an end-user interface.
The primary focus of the product is to reduce readmissions and capture lost revenue by establishing an effective plan and scheduling follow-up services, Bullough-Latsch says. "This is a system that can be paid for through increased revenue so that it does not have to come out of anybody’s budget," he contends.
Another recent development that has found favor with case managers is a new statewide Medicaid prior authorization initiative that will involve all Florida acute care and rehabilitation hospitals and the physicians who admit Medicaid patients to these hospitals.
While the initiative includes only Florida, if it proves successful, peer review organizations (PROs) in other states could follow suit.
The initiative means the end of retrospective case review in the state by the Agency for Health Care Administration.
Beginning January 2002, Keystone Peer Review Organization Inc. (KePRO South) was set to begin a series of regional training seminars and pilot testing at select hospitals reviewing hospital admissions on a prior authorization and/or concurrent basis. The program will become effective for Medicaid hospital admissions that occur on or after March 1, 2002.
Joel Mattison, MD, physician adviser with the department of utilization management and quality assurance at St. Joseph’s Hospital in Tampa, FL, sees this as a very positive development.
"It sounds awfully good," he asserts. If a response is not received within four hours, the patient is automatically authorized. On the other hand, hospitals will have to have 24-hour coverage to accommodate the new program, Mattison adds.
The program is limited to inpatient reimbursement to hospitals and will not affect physician payments. The PRO will establish a procedure for performing prior authorization and concurrent review of inpatient medical/surgical services.
While the initiative involves prior authorization of inpatient admissions to acute care and rehabilitation hospitals, several categories such as children under 21 and dual eligible patients are excluded.
Despite these review exclusions, the new program is expected to have a major impact on internal hospital admission policies and Medicaid claims submissions. KePRO is required to provide prior authorization, admission, and concurrent admission review 24 hours a day, seven days a week. In addition, KePRO is implementing an Internet-based hospital prior authorization program.
The Internet-based system, developed in conjunction with Pennsylvania-based MEDecision, uses InterQual criteria to safeguard against unnecessary or inappropriate use of Medicaid services. It provides clients with an enhanced secure system to perform accurate, confidential medical record review through a remote-user, virtual private network.
Finally, case managers should note a free tool developed by the Agency for Healthcare Research and Quality (AHRQ) that can be used to detect inappropriate hospital admissions for diabetes and 15 other illnesses that can be effectively treated with community-based primary care.
The Prevention Quality Indicators allow users to measure and track hospital admissions using their own discharge data and will provide the information needed to improve the quality of primary care for these illnesses in a community or state.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content