Battling the BBA: Access has a role
Proper admitting diagnosis is key
As Congress looks at legislation to counter the devastating financial effects of the Balanced Budget Act (BBA) of 1997, providers struggle to comply with its dictates while continuing to give patients the care they deserve.
Access managers have an important role to play in ensuring their organizations’ viability, say leaders in the access field and health care consultants charged with designing revenue-saving solutions.
"When the BBA was put in place, it was basically to restrict revenue," says Mark Simonson, a Minneapolis-based director specializing in institutional reimbursement with the consulting firm Deloitte and Touche. "When you have that, an institution has to respond, to develop strategies."
Hospital admissions more complex
What that means for access managers and their employers, Simonson says, is the "need to identify from an admission standpoint the type of patient they can accept in order to be able to provide services within that revenue."
Stand-alone rehabilitation and skilled nursing facilities (SNF), for example, can more easily identify the patients who will be too expensive to care for and not admit them, he adds. "Within a hospital, it gets more complicated" because many are "multi-providers" that operate SNFs and rehab units under a very large umbrella.
With the old system, hospitals got diagnosis-related group (DRG) reimbursement for acute patients and then continued to be paid when those patients moved on to an exempt unit, which received fee-for-service payments, Simonson points out. "What the BBA does is put pressure on all. There may be some patients that to the extent a provider has other alternatives, it may not want to admit to its own rehab unit anymore.
"The decision is not illegal evaluation or payer status," he adds, "but more an issue of organiz -ing units to take care of the patients you can take care of."
As patients come in the door, Simonson suggests, the access manager should assess their needs. "It’s the starting point for where you’re ultimately going to fit the patient into the delivery system.
"To the extent the institution can provide better guidance to the services it provides, that needs to be communicated to the people at the front end," he says. "Alert the patient care manager or the case coordinator that there is something unique about this patient, that he or she will require special attention, and work harder to figure out where that care should be given. Be as clear as you can on admitting criteria."
Determine level at registration
Determining the appropriate level of admission — inpatient or observation — for a patient at the point of registration is more crucial than ever, notes Jackie Birmingham, RN, MS, A-CCC, CMA-C, a consulting associate for the Center for Case Management in South Natick, MA.
Physicians often write an order for an observation bed, but the patient is later admitted as an inpatient, she points out, meaning that hospitals may receive only the lesser reimbursement that accompanies observation status.
"Admitting personnel need to be conscious of what is the expected plan for the patient," Birmingham says, to the point of questioning physician orders that are not supported by the Health Care Financing Administration’s criteria. "So much screening is done based on the admitting diagnosis," she adds. "When admitters get that information to put on the face sheet, they need to get a really good diagnosis."
Screenings may not be reimbursed
At one health care institution she has worked with, Birmingham notes, "the usability of the admitting diagnosis is not even 50%." In one case, she says, diverticulitis was the admitting diagnosis, but the patient had actually had a stroke. In addition to the obvious treatment concerns, such mistakes result in expensive screening that may not be reimbursed, Birmingham adds.
"There also could be a delay in discharge and a loss of money with the DRG," she says. "The value to caregivers of the information admitters collect upfront is just awesome."
One effect the BBA has had on access services, says Beth Ingram, CHAM, director of patient financial services at Touro Infirmary in New Orleans, is to establish that precertification of scheduled patients is no longer just a desirable option, but a necessity.
"It has become more important to ensure that you have gone through the appropriate precertification and verification so you can limit your loss," Ingram adds. "It’s critical that access managers have a process in place so their facility is protected for the service it is providing. There are a surprising number that don’t do that. It can’t be a 60% rate of preverification and preregistration. It has to be 100%."
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