Nurses scrutinize records before bill drops
Hospital prepares for prepayment reviews
Medical City Dallas Hospital is taking a proactive approach to Medicare’s prepayment review process.
When a claim that falls into a category targeted for potential prepayment review has been coded but before the bill has dropped, nurses in the hospital’s Medicare Service Center department perform the final review of the medical record to make sure that everything is in order.
“We’re trying to get ahead of the process by understanding what they’re looking at and making sure the documentation is there before the bill drops. By reviewing the cases proactively, if we have a prepayment review, the documentation is already in place,” says Pat Wilson, RN, BSN, MBA, case management director at Medical City Dallas.
As part of its efforts to cut improper payments, the Centers for Medicare & Medicaid Services (CMS) launched a three-year recovery audit program prepayment review demonstration project in 11 states beginning in August 2012. Under the program, the Medicare Administrative Contractors (MACs) review and affirm or deny claims before they are paid. Hospitals may appeal the prepayment denials through the normal appeals process.
The pilot project is being conducted in seven states with a high level of fraudulent claims and four states with a high volume of short inpatient stays. States included because of a preponderance of fraudulent claims are Florida, California, Michigan, Texas, New York, Louisiana, and Illinois. Pennsylvania, Ohio, North Carolina, and Missouri are included because of short stays. In announcing the project, CMS said it will initially focus on inpatient claims, particularly for short stays, as they have high improper payment rates.
At Medical City Dallas Hospital, pre-billing reviews by the nurses in the hospital’s Medicare Service Center focus on medical necessity criteria for targeted DRGs and procedures that fall under the National Coverage Determination and the Local Coverage Determination.
The hospitals’ orthopedic coordinator, bariatric coordinator, and cardiac coordinator, all of whom are nurses, review scheduled surgical procedures to make sure the documentation is in place before the procedure is performed.
“We know that some procedures will fall under the Medicare Inpatient Only list and will also need to meet the medical necessity guidelines for Medicare,” she says.
When targeted procedures are scheduled, a nurse coordinator uses a tool kit with a check-off list to make sure the documentation supports medical necessity. For instance, with total joint replacement surgeries, the documentation in the record should include level of pain, conservative treatment that has been tried, patient mobility, and other indications that the surgery is necessary.
“The hospital partners with physicians to ensure that medical necessity is in place prior to the procedure. Once the procedure is completed, the unit case manager reviews it again for criteria. The Medicare Service Center becomes the final safety net prior to billing,” she says.
Orthopedic procedures are the biggest focus of the prepayment reviews, she says.
In those cases, the orthopedic coordinator reviews the supporting documentation that is included with the request for scheduling the procedure. If the documentation is complete, the procedure is scheduled. If the coordinator thinks additional documentation is needed, the physician’s office is asked to fax over the information, which becomes part of the medical record.
There was a learning curve when the hospital started the procedures, but the physicians have been very supportive in working with the hospital to ensure all the elements that demonstrate medical necessity are in the record, Wilson says.
“We work closely with the physicians so they understand the requirements. Most surgeons are well-versed in Medicare requirements, and they have provided information to insurance companies for preauthorization for many years. Medicare’s move into prepayment review is in many ways similar to the preauthorization required by insurance companies,” Wilson points out.
Sources
- Brian Flood, CHC, CIG, AHFI, CFS, partner with Brown McCarroll, LLP, in Austin, TX. email: [email protected]
- Deborah Hale, CCS, CCDS, president and chief executive officer of Administrative Consultant Service, Shawnee, OK. email: [email protected]
- Pat Wilson, RN, BSN, MBA, case management director, Medical City Dallas Hospital. email: [email protected]
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