Proactive approach reduces denial rate to 5.8%
CMs work with medical director on potential cases
The denial rate at Southern Ocean County Hospital dropped from the double digits to an average of 5.8% in less than 18 months, thanks to a proactive approach by the case management staff and the medical director.
"The case managers and medical director Sekander A. Ursani, [CPE, MD] work as a team to reduce denials and avoidable days and ensure that the patients get timely and efficient care. If the case managers foresee a denial, a downgrade in acuity level or length-of-stay issue, they can contact him immediately," says Marilyn Butler, RN, MSN, CCM, director of case management at the Manahawkin, NJ, hospital.
At Southern Ocean County Hospital, the case managers and social workers are unit-based and work as a team, with two case managers and a social worker covering 32 beds. The team works eight-hour shifts Monday through Friday.
Butler and Ursani make rounds every day on every unit, sitting in on rounds that are in progress whenever possible. Alternatively, they meet with the case managers, social worker, and clinical coordinator of the unit while the nursing staff come in one at a time to discuss their cases.
"We go over every case every day, looking at length of stay, acuity, and if there are issues in moving the patient forward. We look at the managed care cases to determine if we are being reimbursed at an acute level or if we have been downgraded and, if so, why," she says.
Access to data
In the case of patients who have been downgraded, Ursani talks with the case manager, reviews the chart, and calls the medical director at the managed care company if he feels the patient still is at the acute level.
"He has a good rapport with the medical directors at the managed care companies and has been very successful in getting denials and downgrades overturned by using this proactive approach. The case managers can call him at any time if they see a case that may be denied or downgraded, rather than waiting for him to come on the floor," Butler says.
When Butler was hired to create a case management program at Southern Ocean County Hospital in February 2005, the hospital had utilization review nurses and social workers who functioned separately, an unacceptable average length of stay of 5.1, and a denial rate of 14.1%, she recalls.
"When I arrived, the department lacked the ability to monitor the reasons for denials and delays in progression of care and also lacked continuity in how denials were being handled. We knew that we had to become concurrent in our denial management. In the past, denials had been dealt with retrospectively," Butler says.
Before she began the denials management initiative, Butler developed a dictionary for the computer system that includes reason codes for delays and denials and avoidable days for Medicare patients.
"I reviewed some of the dictionaries that other hospitals have developed but made ours very specific to what we are seeing so we can better track denials and delays in service," she says.
Now the case management team has easy access to data that help them identify problems and take steps to correct them.
"Now that we have the codes that show the reason for delays, we are able to identify the system delays and work with the department on ways to remove the roadblocks to discharge," she says.
For instance, the team discovered that getting the results of stress tests was holding up the discharge of some patients.
"We have a lot of patients who come in with basic chest pain and, as long as their cardiac enzymes are normal and the stress test is negative, they can go home," she says.
Butler worked with the head of the department to work out a process that expedites the test results for patients who are ready for discharge pending the stress test results.
Now when a patient's discharge hinges on the stress test results, the case manager calls the department and requests that the patient's file be put on the top of the pile for the doctor to read.
"The case managers are proactive in getting all the pieces together and making sure that every test is done and the results are back so the patient can move through the continuum," she says.
The case managers take a proactive approach to moving the patient through the continuum, alerting the physician far in advance of discharge or transfer if a patient is going to need an evaluation or test.
For instance, swallowing evaluations frequently hold up the discharge of stroke patients.
The case managers make sure that the physicians order swallowing evaluations for stroke patients early in the stay.
As soon as the case managers know that a patient probably is going to be moved to a subacute rehabilitation unit, they leave a note for the physician asking for orders for a physical therapy evaluation.
The hospital has created transfer forms to be used when a patient is transferred to a rehabilitation unit, a nursing home, or other post-acute care facility.
The case managers work closely with the physicians to get the forms filled out up front, rather than having to fax them over to the office.
The team has tackled the problem of patients who come to the emergency department with a psychiatric crisis and end up staying there from 24 to 48 hours because no one is available to screen them for admission to a psychiatric hospital.
"What we found is that there aren't enough screeners and that these patients are staying an inordinate amount of time until we can get them cleared to go to the psychiatric hospital," she says.
As a result of meetings between hospital officials and a local psychiatric hospital, the case managers and social workers who work in the emergency department are going to be trained as crisis screeners.
The hospital is not reimbursed for keeping the patients until the screening takes place. In addition, the patients are taking up beds that could be used by another patient.
"It's not fair for the patient to be lying in bed and not getting the psychiatric care they need. It is a benefit for the patient to be moved as quickly as possible," she says.
When Butler arrived in 2005, Southern Ocean County Hospital had four utilization review nurses and four social workers.
Now, the hospital has four social workers and nine full-time case managers, along with several per diem positions. The case managers are assigned by unit and also cover the emergency department.
The case manager-social worker team on each unit conducts concurrent reviews of cases on a daily basis to make sure patients meet criteria to remain in the hospital.
The case manager who covers the critical care unit also is the gatekeeper for denials and keeps a close watch on denied days and the reasons for the denials.
For more information, contact Marilyn Butler, RN, MSN, CCM, director of case management, Southern Ocean County Hospital, Manahawkin, NJ. E-mail: [email protected].
The denial rate at Southern Ocean County Hospital dropped from the double digits to an average of 5.8% in less than 18 months, thanks to a proactive approach by the case management staff and the medical director.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