Clinical expertise up front makes access role easier
December 1, 2000 8 minutes read
Clinical expertise up front makes access role easier
Avoid playing catch-up later
With the increasing need for clinical expertise at the point of registration, the joining of access and case management seems to be a health care marriage made in heaven.
Some cutting-edge hospitals are realizing that determining clinical appropriateness before care begins makes a lot more sense than playing catch-up later, especially when reimbursement denials can play havoc with a facility’s bottom line.
At Houston’s Memorial Hermann Southwest Hospital, six registered nurses have been part
of the access department since January, reports Ollivene Hickman, CHAM, director of patient access services. They’re part of an access staff
of 81 that handles preadmission verification, registration, scheduling, bed management,
financial counseling, and telecommunications.
"The reason we wanted to do this is because of the need at the time of reservation to begin the prescreening," Hickman explains. "It is care management, but it’s the prior to,’ the prescreening for medical necessity and clinical appropriateness."
The 500-plus-bed facility, which has 5,500 patients per month passing through its emergency department (ED), gets 50% of its inpatients through the ED, she says. The access nurses, with 24-hours-a-day, seven-days-a-week coverage, are on hand to make sure those admissions are categorized appropriately, Hickman adds.
"Any time a patient is in the ED and there’s a decision to admit, our access nurse prescreens to make sure that patient [is assigned to] the appropriate level of care," she says. "We’re always tight on beds, so we definitely do not want to get a patient in the intensive care unit and find out an hour later that [the patient] does not meet the criteria."
The access nurses prescreen "all direct admits," Hickman notes, including patients who are admitted from a physician’s office or through the transfer center. The nurses obtain orders from the transferring facility before those patients arrive, she adds.
In addition to their primary mission of prescreening for clinical appropriateness, the access nurses also make sure Medicare Advance Beneficiary Notices are processed correctly, Hickman notes.
Reimbursement denials have dropped significantly since the program began, she says. "Our denial rate is very low."
The reason the access nurses have worked out so well, Hickman says, "is that we’re the upfront case management piece. Once the person becomes an inpatient, we’re out of it." The hospital’s case managers no longer have to double back because the correct designation wasn’t made initially, she adds. "Once we hand [the account] over, it’s in good order."
Access nurse builds visibility
A strong nursing presence in the access department is "critical to the function of tying in with the rest of the hospital," says Marne Bonomo, RN, PhD, director of patient access at the 1,400-bed Clarian Health in Indianapolis. In her job, which she assumed two years ago, and at the two facilities where she worked previously, she was the first nurse to hold the position of director of access, Bonomo notes.
Having an access director with nursing credentials, she says, "builds the visibility of the department within the organization. Frankly, nurses tend not to trust anyone who is not a nurse and see the financial division as some kind of enemy to patient care. Knowing there is somebody on this end who has that [nursing] insight builds a better comfort level."
Thirteen of the 150 access employees Bonomo oversees are registered nurses, including the three who make up a recently formed denials management team. The effort began in August 1999, she says, with herself and one nurse. "Now there are two nurses and clerical support under the supervision of the manager for certification."
The mission of the denials management team, which performs a function often performed in the business office or utilization management department, is to handle development letters from Medicare and respond to letters from fiscal intermediaries asking for more information, Bonomo says. These nurses appeal medical necessity denials and track and trend denial activity, she adds.
"I used to think we could recoup large dollars by working denials, but I’ve discovered that the real goal is to prevent denials, find out what the causes are, and educate the organization for better account management," Bonomo says. Remedies include improving chart forms, correctly designating patient types, and educating physician offices and care management personnel as to proper documentation, she says.
Denials can result from incomplete documentation, Bonomo notes, including discrepancies in the times that observation patients are admitted and discharged. "The time that an observation patient leaves must be exact. You can’t just [process] it in a batch at night."
Another 10 nurses make up the certification team, reporting to Bonomo but acting as a support group for care management, which then reports up through the medical staff, she says. The function performed by the certification nurses "normally happens in a utilization review [UR] department," Bonomo explains.
Because Clarian doesn’t have a UR department, the certification nurses feed the necessary financial and insurance information to the hospital’s care coordinators at the time of admission or as they attempt to defend patient stays, she says. The care coordinators, in turn, feed clinical information back to the access staff. "Access staff and certification nurses are the liaison with the insurance companies."
Again, because there is no UR department, the certification nurses assist the care coordinators in managing cases on patient floors, Bonomo says.
Clarian’s focus on ensuring accurate medical information on the front end has been further enhanced, she adds, by bringing Clarian’s financial counselors under the access umbrella. "The financial counselors used to report to patient financial services, but we recently brought them on board in access," she says. "We redesigned their job descriptions and upgraded the position.
"We have been successful in moving these very valuable people up one pay grade in this process," she adds. "Recently we lost five employees in one day to an outside department that paid more for similar skills. This really made us take notice of the importance of these skills. It takes a long time to acquire the knowledge necessary for managing government programs."
Under the new arrangement, these employees are divided into benefits-verification specialists and financial counselors for self-pay patients, she says, and are able to handle patients more efficiently. Those who work with the self-pay population screen patients for possible inclusion in government programs, Bonomo adds. "Before, everyone handled all patient types and effective prioritization was next to impossible."
There have been challenges associated with rearranging the staff, she says. "Their job descriptions are changing and in some cases employees are moving to different campuses, different shifts, and different responsibilities. So far, employees have been remarkable in their patience and support for this change."
Bonomo attributes the cooperative effort to the supervisors who come to patient access with their staff. "Staff have been involved in the plans from the outset, and the supervisors have provided a clear and upbeat message regarding the improved functionality that will be possible. There will be faster communication, better account resolution, happier customers — including preadmitting, certification, and patient financial services staff as well as patients — and ultimately, improvement
to the bottom line."
All patients treated the same
At the University Hospital of Arkansas in Little Rock, the admissions department has a registered nurse who screens all elective scheduled admission requests, says M. Holly Hiryak, director of hospital admissions. The RN makes sure there is verification or authorization for the admission and looks at medical necessity for self-pay patients, Hiryak adds.
The department uses InterQual software —- from Marlborough, MA-based InterQual Products Group, a subsidiary of McKesson-HBOC — to provide guidelines ensuring the level of service the physician has requested for the patient is appropriate, she notes. "Does it meet inpatient or observation criteria, or could it have been done in same-day service?"
If the service level requested doesn’t hold up to scrutiny, the nurse calls the physician, Hiryak says, and tells him or her, for example, that the criteria support a vaginal hysterectomy but not an abdominal hysterectomy. Usually the physician will change the order, she adds.
The process primarily applies to self-pay patients, who make up a fair portion of the hospital’s patient population, and the idea is to make sure all patients are treated the same, Hiryak says. With insured patients, she points out, the hospital calls the insurer for prior authorization and, if that authorization is given, indicates the person requesting the admission has provided the necessary clinical data.
In the past, the hospital accepted self-pay patients without requiring the same scrutiny, she adds, but that is no longer the case. "We do require that [physicians] provide medical information for elective scheduled self-pay patients. This process ensures that all admissions are screened consistently. If the required information is not provided prior to the scheduled procedure or admission date, the case will be cancelled."
At present, indications are that there is an extremely low number of denials for insured patients who are referred by physicians, Hiryak says, so the department does not routinely check medical necessity for those patients. "We are beginning to look at denials to see if it is worth tightening the controls at the access point for those patients," she says, and procedures will change if the numbers so indicate. All observation cases are run through InterQual criteria, she notes.
The admissions nurse works in the insurance verification room and also serves as a resource for staff who are unsure of medical terminology, she adds.
In addition to having its own RN on-site, the admissions department ensures the quality of its medical data through a particularly harmonious relationship with the hospital’s case coordination department, Hiryak says.
"If we have a patient admitted through the emergency department or by a physician, we call it in to the payer the next morning to get authorization," she says. "Often they request immediate medical information, and so we bump up [the case] to the case-coordination department. We have a good relationship."
Smoothing the process, she notes, is a system of e-mail communication whereby messages are sent to a group, not individuals. "Whoever’s assigned to do so picks up the message, so we don’t have to track down any one individual. There is always someone assigned to pick it up, so if someone is on vacation, it doesn’t sit there untouched."
If a nurse or social worker in the case coordination department discovers a piece of demographic information that admitters missed or the patient didn’t provide, it is passed down to the admissions department in the same way, Hiryak says.
The nurse or social worker might find out, for example, that a patient has secondary insurance he or she remembered as plans for post-discharge care or the use of durable medical equipment were being made, she explains. "Or if a trauma case comes in, it may be [termed] self-pay because we may not see the family for a day or two," Hiryak adds. In such cases, she notes, the social worker eventually may meet with the family and find that, in fact, the patient is covered by Medicaid.
[Editor’s note: For more information on InterQual software, call (800) 582-1738 or visit the Web at www.InterQual.com.]
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