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A multilevel denials management process generates $1 million or more in recovered revenue annually for inpatient accounts at the University of Pittsburgh Medical Center (UPMC), a larger health system with 20 medical facilities.
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In its final rule for the Outpatient Prospective Payment System for calendar year 2008, the Centers for Medicare & Medicaid Services (CMS) took the first steps linking payment for outpatient services to the quality of care received by expanding the Hospital Outpatient Quality Data Reporting Program and requiring hospitals to report on outpatient quality measures for the first time.
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Six Sigma projects at Sharp HealthCare hospitals have dramatically shortened the time that elapses between the time that discharge orders are written and the time the patient leaves the acute care setting.
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Increased patient involvement in their own care is encouraged by The Joint Commission and other organizations as one of the keys to improving patient safety. In fact, "encouraging patients' active involvement in their own care" is one of the National Patient Safety Goals.
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Having a team of case managers dedicated to Medicare compliance reduced the number of admission denials from 221 in 2006 to just two by late December 2007 at The Valley Hospital in Ridgewood, NJ.
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Making patient bills more user-friendly not to mention ensuring that they are actually accurate continues to be a focus in the health care industry.
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When it comes to talking with physicians about documentation or admissions criteria, it's often not what you say but how you say it that helps you get an answer.
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It's frustrating when you point out that a patient doesn't meet acute care criteria or that documentation in a chart is not complete and nothing happens, even if you take it to your physician advisor.
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Remember that the case manager-physician relationship is like a marriage and you have to keep working at it to make it a good one, says Steve Blau, MBA, MSW, LCSW-C, director of case management for Good Samaritan Hospital in Baltimore.
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Working for 10 years as emergency department nursing manager at St. Mary's Hospital in Tucson, AZ, Cassandra Pundt, RN, CEN, recalls she was constantly struck by the "tremendous need" for a patient advocate specifically dedicated to the ED.
