Reorganization helps improve reimbursement
Reorganization helps improve reimbursement
CMs ensure documentation, medical necessity
In the first year after reorganizing the case management department, Lake Granbury (TX) Medical Center, a 59-bed facility, substantially increased reimbursement by improving documentation and saved $35,000 by putting case managers in charge of getting Medicaid forms signed, rather than relying on an outside vendor.
"This is a small hospital without a cardiac or neurological unit, and we have to be careful with the resources we have and to make sure that everything is correctly documented and that we move every patient through the continuum as quickly and safely as possible," says Lyn Clark, RN, BSN, director of case management.
That hasn't always happened, says Clark, who was recruited in 2005 by the chief executive officer, who charged her with organizing the case management program.
She discovered a hospital with two case managers who were working without direction, often doing jobs, such as picking up blood from the blood bank, that could be done by staff with a much lower level of training.
The case managers were called on to help out the nursing staff by giving medications or seeing the patient at the bedside. "We have to focus on using our resources wisely. If we're not helping the facility to be financially solvent and the hospital closes its doors, we won't be serving anyone," Clark says.
Clark started by developing a training program for the case managers. "In a small town, you have to grow your own. People who have been nurses for 20 years are not necessarily good case managers. If someone has compassion, common sense, and has the ability to do critical thinking, they can learn the principles of case management," she says.
The hospital has two FTE case managers, split into three positions. Two of them work four days a week. The other works two days. Between them, they provide coverage seven days a week, 10 hours a day.
Clark has created educational modules to teach her case managers about Medicare and Medicaid rules and regulations, DRGs, case mix index, length of stay, and other information they need to do their jobs.
She continues to educate her staff regularly about changing regulations. "As case management director, my role is to digest and understand the new regulations and to feed it to my staff in increments," Clark explains.
The case managers received training on basic computer skills and learned to set up worksheets for tracking and trending instead of keeping data on pieces of paper.
"I had to get the staff to learn to think differently and to avoid duplication. You can be busy and not be productive. They were doing a lot of busy work, like retyping reports to make them look good," Clark says.
When Clark started work at the hospital, she ran data on the hospital's DRGs for the previous 12 months. "We had an aging population and no cases of complex pneumonia. That was a clue that the documentation was not appropriate," she says.
When Clark pulled the charts on a sampling of patients, she found a lot of problems.
For instance, there was an 80-year-old whose record said she had simple pneumonia but who had underlying hypertension and diabetes and was being treated for both conditions while she was in the hospital.
"Nobody was here to point out to the doctor that the documentation had to reflect complex pneumonia in order for the facility to be paid. Once we began delving into the documentation, it was like peeling an onion. We uncovered layer after layer of issues," Clark says.
In one year, the hospital's case management staff substantially increased reimbursement by assuring that patients' conditions were appropriately documented.
"By appropriate documentation, we increased case mix index, and that added hundreds of thousands of dollars to our reimbursement," she says.
Clark worked with the case managers to make sure they reviewed all Medicare one-day stays daily and to ensure that patients on Medicare stay for the full DRG length of stay if they will be transferred to rehab.
Now the case managers work closely with the physicians to ensure that the documentation is sufficient so the hospital will be reimbursed.
"We inform the physician that we want the document to show a clear picture of the patient and the true severity of illness and that we can't expect a nonmedical person who does coding to make that leap. They don't have the background that a physician or a nurse does," Clark says.
The hospital saved $35,000 a year when the case managers assumed responsibility for getting Form 3038 signed as required by Medicaid for newborn infants, instead of paying an outside vendor to do it. "We were paying the vendor $400 a form and were able to show each month how much we saved," she recalls.
In the past, if patients came into the emergency department with no physician of record and couldn't afford medication, the hospital would admit them for 10 days and give them the antibiotics. "As case managers, we should know the community resources such as drug programs that give indigent patients access to antibiotics. Now, we get the patient their antibiotics and send them home," Clark says.
The case managers monitor improper admissions and inappropriate use of resources. "We save the hospital beds for the patients who truly need to be in that bed," she says.
When you are the first case manager at a small hospital, you may not feel very popular, Clark says.
"The doctors don't like you because you don't let their patients stay three weeks. The nurses think you're cruel to push for appropriate discharge for patients. The family members are mad because they want grandma to stay in the hospital to rest," she says.
Being a case manager in a rural setting often means that you're a lone wolf, Clark says. "The system didn't break overnight. It won't be fixed overnight. Often you have to think outside the box," she says.In the first year after reorganizing the case management department, Lake Granbury (TX) Medical Center, a 59-bed facility, substantially increased reimbursement by improving documentation and saved $35,000 by putting case managers in charge of getting Medicaid forms signed, rather than relying on an outside vendor.
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