Access Management Quarterly

Initiatives help cut write-offs, improve compliance

Case managers review charts daily

Through a series of case management initiatives, Methodist Medical Center in Oak Ridge, TN, has dramatically reduced its emergency department’s Medicare write-offs and improved its compliance with core measures.

The Medicare write-offs have dropped from an average of $40,000 a month to less than $2,000 a month, reports Coletta Manning, RN, MHA, CPHQ, director of clinical effectiveness and quality improvement.

In the third quarter of 2005, emergency department physicians were 100% compliant with the core measures and would document when the recommended procedures were not appropriate for their patients, Manning adds.

The hospital has one full-time case manager and one part-time case manager who work in the emergency department and in same-day surgery, respectively.

The case managers go to the charts on a daily basis to make sure the core measures have been followed and that the procedures ordered for the patients meet medical necessity criteria.

Lisa Lane Byrd, RN, BSN, CCM, the full-time emergency department case manager, attributes the savings and compliance with the core measures to improved documentation by the emergency department clinicians, improved coding by the emergency department coders, and changes in routine treatment.

"When we first put a case manager into the emergency department, her objective was to work with physicians and make sure that they were documenting appropriately," Manning says.

The case management department examined the highest volume of procedures that were being written off and focused on those first.

For instance, when the initiative started, physicians routinely were ordering three sets of two different cardiac enzymes a few hours apart, for troponin-I and CPK, enzymes that indicate an acute myocardial infarction, on all cardiac patients.

"Medicare pays for one, but they were routinely doing three of each," Manning says.

When a literature review showed that ordering all of the tests was not necessary, Byrd met with the emergency department physicians and the hospital’s cardiologists to determine if the routine procedures could be cut or eliminated without harming the patients.

"We no longer routinely draw CPKs in the ED, and we routinely draw only two troponin-I’s. This has substantially decreased the monetary loss without compromising patient care," Byrd says.

ED physicians were ordering prothrombin times and partial thromboplastin times, tests to determine how fast blood coagulates, as routine work-ups for patients with a variety of conditions.

"Both are not always necessary. When we talked to the physicians at one of their monthly meetings, several physicians said they ordered them out of habit and had never thought about it being a reimbursement issue," Byrd says.

Now, the physicians are more selective about which patients get the tests, and they don’t always order them together, she adds.

The emergency department case managers shadow the emergency department physicians, following them for a period of time, checking their documentation, and pointing out where they could make improvements.

"We tell them we don’t expect them to keep up with all the criteria. It’s constantly changing, and it’s different with Medicare and commercial insurance. Most of the time, the doctors don’t even know what type of insurance the patient has, and it’s up to us to fill in the blanks," Manning says.

When the case managers started the project to shadow the physicians, Byrd brought it up at one of the monthly staff meetings.

"We told them we were looking at how to improve documentation, to make sure patients met the medical necessity criteria for procedures, and to make sure that the core measures are being followed," Byrd says.

None of the physicians opposed the plan. In fact, some volunteered to be the first ones shadowed.

Byrd works in the ED Monday through Friday from 8 p.m. to 4:30 p.m. The ED doctors rotate on various shifts, and eventually she shadowed all of them. "When we first started, we targeted the ones that were struggling the most. The doctor who had the most write-offs asked me to help," she says.

When she shadows physicians, Byrd stays out of their way when they’re seeing patients and reviews the charts behind them. She chats with the physician between patients, checking with him or her on documentation and keeping a running tally of what she accomplished each time.

"If I find somebody who is a core measure candidate, I put their patient identification sticker on my clipboard and check to make sure they received the recommended procedure and it was documented," she says.

When the emergency department case management initiative began, shadowing the physicians was a major area of focus. Now, the case managers shadow the physicians only occasionally, concentrating on other areas of concern.

"We’ve done a lot of work with the coding staff and the physicians. Sometimes the coders didn’t code something in the chart because they didn’t recognize what it was. We continue to work on improving coding on a daily basis," Manning says.

When the hospital’s business office write-off program rejects an emergency department laboratory test, X-ray, or other procedure because of lack of medical necessity, the case managers are notified and review the chart.

If the necessary symptom or diagnosis is in the record but hasn’t been coded, she notifies the emergency department coder, who adds them. If the physician hasn’t documented medical necessity, the case manager asks the physician to review the chart and explain what symptom of diagnosis or clinical judgment prompted him or her to order the test.

"If the clinician is unable to add the symptoms or diagnoses, the test is written off and the deficiency is kept on file," Byrd adds.

Byrd creates a monthly report for each physician, comparing their write-offs and compliance with the core measures with other physicians, who are not identified by name.

"This created some competition. Everybody got very interested in ways to decrease the write-offs and improve core measures," Byrd says.

The case management team presents the Medicare write-offs and core measures compliance results each month at the emergency department’s physician meeting.

If a physician has a month without a write-off or core measure deficiency, he or she is given an award, as part of the hospital’s incentive program. The write-offs and incentive awards are considered during the re-credentialing process.

The emergency department case managers and inpatient case managers work together to identify deficiencies in meeting the core measures and to educate the staff. The inpatient case manager completes core measures forms for each appropriate patient, identifying whether the core measures goals have been met.

She notifies the emergency department case manager if the emergency department staff are involved. The ED case manager provides one-on-one education to the physician and notifies the appropriate emergency department shift manager, who counsels the nurse.

The case management staff post "friendly reminders" of the core measure goals and requirements in the emergency department, staff and physician break rooms, and nursing stations and compile monthly "core measure report cards" for each physician.

The case management department has worked hard to create a rapport with the emergency department staff, Manning says.

"We worked to show the emergency room doctors that the case managers aren’t just the money police. We do a lot of things like find community resources for patients who are homeless or who can’t pay for their drugs. We’ve even arranged nursing home placements direct from the ED," she reports.

Manning has hired a coder with a background as a coding instructor to help the physicians throughout the hospital understand what they need to document. She estimates that the coder has helped the hospital increase its revenue annually by $300,000 to $400,000.

In the same-day surgery arena, the case managers work with physicians and their office staff on criteria for inpatient admission.

For instance, Medicare specifies that some procedures are inpatient only. If they are done as same-day surgery, the hospital doesn’t get paid.