Clinical managers ensure accuracy, speed payments

The biggest change made during the reorganization of Gaston Memorial Home Care in Gastonia, NC, was the multidisciplinary team approach in which nurses and therapists report to a clinical manager. Not only is this approach helpful for patient care management, but the streamlined approach makes it possible for the agency to file accurate Request for Anticipated Payments (RAPs) earlier than the old system that relied upon utilization review nurses to approve claims.

Previously, claims were not reviewed for up to two weeks after a patient's admission, so RAPs were delayed or sent with incorrect coding, says Kimber Walters, MBA, executive director of the agency.

The new staffing structure now places the responsibility for review of the OASIS (Outcome and Assessment Information Set) by the team's clinical manager who does have the clinical and coding knowledge to evaluate the assessment, she explains.

Once the field nurse or therapist completes the OASIS form on a new patient, the clinical manager reviews it for coding accuracy and identifies any discrepancies in codes that need to be addressed before sending the form to the OASIS clerk, Walters says.

"The OASIS must be completed by the field nurse within 48 hours of admission, then the OASIS clerk is able to take the form that has been reviewed by the clinical manager and generate the RAP within five days," she explains.

"We still have utilization review double-check the claim, but that is done on the back end of the process after the clinical people have reviewed the form." Because coding is reviewed by the clinical manager upfront, there are fewer corrections to the RAPs, and payments are more timely, Walters adds.

One of the key reasons the new process runs smoothly is the clinical manager's direct contact with the field staff, she explains. When a utilization review nurse found a discrepancy or a missing code, she would call the field nurse and ask for an explanation.

"Because the utilization review nurse was not the field nurse's supervisor, there was less urgency to call back immediately," Walters says. "Now it's the nurse's boss calling to ask for information, so responses are much quicker."

That process also gives them an opportunity to identify trends in coding mistakes and further educate the nurses, she adds.

"The manager can immediately talk with the nurse to correct mistakes so that the nurse doesn't unknowingly continue to code the next several days' worth of OASIS forms incorrectly," Walters says.

Not only is there one-on-one teaching occurring when the manager is talking with the nurse about why one code is used as opposed to another, but if the same mistake is made by several nurses, the agency has a chance to offer further training to all nurses, she explains.

The interaction between the clinical managers and the field nurses has improved the entire process of assessment, coding, and OASIS completion, Walters notes.

"We've learned that you can't solve financial problems without including the clinical staff in the solution," she adds.