Case managers can help improve reimbursement
Educate clinicians on preventing service delays
With payers sharpening their pencils and refusing to pay for what they deem to be unnecessary hospital stays, case managers need more than ever to help their hospital balance the clinical and financial aspects of health care.
Case managers are the perfect people to assist in improving quality of care across the organization because they have an overall picture of what is happening within the entire hospital, says Teresa C. Fugate, RN, BBA, CPHQ, CCM, manager at Pershing, Yoakley & Associates, a Knoxville, TN-based health care consulting firm.
Case managers know where the delays are, where they can assist and provide more information to the physician, how the populations are being serviced, and where there are opportunities for improvement, Fugate adds.
They should help train the clinical people on how they do what they do to prevent delays in services and reduce medical errors.
Consider these scenarios:
- A physician admits a stroke patient on Medicare and orders neuro checks every two hours, but a swamped nursing staff doesn't do them with that frequency.
The hospital could face the possibility of not being reimbursed for that part of the patient stay.
"Medicare is beginning to review medical necessity from the point of view that if the physician ordered the service and the nurses didn't provide it, the patient didn't need to be in the hospital," Fugate says.
Medicare is looking for quality of care, so not following the physician's orders not only affects reimbursement but also affects how the hospital is perceived as providing quality of care, she adds.
Private insurers are also starting to check closely to determine whether services ordered by the physician are actually provided, and, in some cases, might ask for the results of the two-hour neuro checks.
- A physician orders a consultation, but the consulting physician doesn't see the patient for a day or two. This causes a delay in services, and the patient spends a day in the hospital waiting for the consultation.
More and more insurance companies are refusing to pay for avoidable days in the hospital, Fugate says.
She suggests that case managers keep a log of delays in consultation, add them up at regular intervals, and distribute them to the physicians.
"Physicians may not realize that they are causing the problem, but if you can collect the data and show how many times the delays occurred and how many times the hospital didn't get paid, it can have an effect on the physicians' actions," she adds.
- A physician orders a chest X-ray, with orders to dismiss the patient if the X-ray is clear. The patient doesn't get the X-ray until later in the day and stays overnight because the radiology staff already have gone home.
This is another example of an avoidable patient day that may result in a loss of revenue, Fugate points out.
"X-ray tends to do the outpatient X-rays first because the inpatients are always going to be there. It's not always appropriate or efficient when you talk about keeping a patient whose care may not be reimbursed," Fugate says.
This is where the case manager can intervene and make sure the X-ray is taken care of early in the day.
"Case managers are in a primary position to collect data that can show delays in services and variations in care and show the physicians and hospital departments that these not only affect quality of care but cost the hospital money," she says.
If a physician's orders aren't followed in the case of the neuro check, sometimes the patient may have bleeding that's not caught, and the patient could end up being disabled or dying.
"It's not just a quality-related issue. It's also a financial issue and a risk-related issue. The three are connected, and case managers can really assist," she says.
With payers sharpening their pencils and refusing to pay for what they deem to be unnecessary hospital stays, case managers need more than ever to help their hospital balance the clinical and financial aspects of health care.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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