ED case managers are crucial to help maximize reimbursement

As gatekeepers, you must ensure all admissions are appropriate

Today's hospitals are facing a shrinking pool of healthcare dollars along with increased scrutiny from Medicare, Medicaid, and commercial payers and strong penalties for fraud and abuse. This trend makes it essential for case managers in the emergency department to screen patients to make sure that all admissions are appropriate and that patients are placed in the right level of care.

"Patients must be assigned to the appropriate level of care from the moment they arrive in the hospital, whether it's being admitted as an inpatient, treated and released, or admitted to observation," says Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Case Management Concepts, a case management consulting firm based in Dallas.

"Emergency department case managers serve an important role in making sure hospitals have the right patients occupying inpatient beds and that patients are not inappropriately readmitted to the hospital."

The Centers for Medicare and Medicaid Services (CMS) has unleashed a bevy of auditors that are scrutinizing Medicare and Medicaid claims, looking to recoup payment and, if there appears to be a pattern of fraud, referring the case to law enforcement. Commercial insurers are following suit and in some states have already launched audit programs similar to the Medicare and Medicaid Recovery Audit Contractor (RAC) programs.

Brenda Keeling, RN, CPHQ, CPUR, president of Patient Response, a Durant, OK, healthcare consulting firm says, "Medicare is working collaboratively with insurance companies to streamline and standardize healthcare. The 2011 Office of Inspector General's Work Plan holds individual states accountable for ensuring medical necessity and preventing fraud and abuse. In addition to facing audits related to Medicare and Medicaid claims, hospitals may find themselves facing increasing scrutiny for medical necessity of claims to other insurance companies."

In the past, hospitals didn't have the incentives to monitor hospital admissions the way they do today. Almost every patient who was presented was admitted, maximizing hospital volumes and reimbursement.

"There was so little oversight that there was only a small chance that the payers would try to recoup the reimbursement," Keeling says. "People think that because CMS has threatened in the past to crack down and hasn't done so, that it won't happen now. But, we're in a new ballgame."

Now, healthcare costs are increasing and taking up a huge percentage of the gross national product, and hospitals are facing cuts in reimbursement as well as an increasing number of patients without insurance. It's essential for hospitals to take a proactive approach to managing admissions and make sure that every patient who is admitted belongs there and is in the appropriate level of care, adds Joanna Malcolm, RN, CCM, BSN, consulting manager, clinical advisory services for Pershing, Yoakley & Associates in Atlanta.

If non-acute patients occupy inpatient beds, hospitals are likely to experience capacity issues and denials from commercial payers. In addition, the hospital is subject to having to give back money to CMS when the auditors uncover inappropriate admissions.

"The level of care that patients are placed in is one of the big areas of focus from the RACs (Recovery Audit Contractors). This means that having patients in the appropriate level of care is the first line of defense for hospitals," Cesta says.

Emergency department case managers are an extra pair of eyes for the clinical documentation improvement staff and can work with the emergency department physicians to ensure that the documentation accurately represents the patient's condition, she points out.

The RACs are looking at chest pain and syncope admissions because they might not meet medical necessity criteria, Cesta says. "Having emergency department case managers who are educated on some of the key clinical documentation improvement concepts can be extremely helpful in getting documentation right at the onset," she says.

Case managers must be involved in the process of admission and review the case before it is registered for admission. "Once a patient is registered for admission, it's more difficult and complicated to cancel an inappropriate admission than it would be to stop the admission from happening in the first place," Cesta adds.

Having case managers in the emergency department to ensure that admitted patients meet inpatient criteria helps the hospital avoid filing a Condition Code 44 or a provider liable bill modifier if a retrospective review shows that the admission was inappropriate, Keeling points out.

Case managers in the emergency department can do more than just make sure the hospital doesn't lose reimbursement or face additional scrutiny from payers, Malcolm points out. Making sure patients who are admitted meet acute care criteria is important not only because it helps the hospital bottom line, but also because it avoids filling beds with patients who don't need to be there, Malcolm says. "When patients are in the hospital, they are subject to exposure to diseases and infections and may be at risk for falls. We don't want to hospitalize patients unnecessarily and run the risk of them getting sicker," she adds.

Case managers in the emergency department have an opportunity to impact length of stay by beginning pre-admission discharge planning while the patient is still in the emergency department. They can talk to the family members who accompany the patient and/or the ambulance staff and get information on the patient's medical history, his or her living situation, and any potential issues after discharge. This information saves the case manager on the floor the problem of tracking down family members who might visit only in evenings when case managers are not on duty.

They can facilitate the initiation of care such as getting tests and procedures performed early on and making sure that appropriate patients receive the treatment covered in the core measures, such as antibiotic administration, Cesta says. If it appears that the patient is going to need post-discharge services, such as rehabilitation or home care services, emergency department case managers can start the ball rolling by finding out if the patient has a preference for services and setting up whatever screening is necessary.

Hospitals can eliminate or at least reduce inappropriate admissions if they have someone in the emergency department to set up services, such as home health, for patients who can't be safely sent home but do not meet admission criteria. They can screen for social admissions that still occur today, particularly in small communities, Keeling says.

When families bring in their loved ones with dementia and other conditions because they can no longer care for them, emergency department case managers or social workers can help them access assistance programs such as elder services, meals on wheels, home health aides, or adult day programs. They can intervene with patients who return to the emergency department over and over and work with the emergency department staff to create a plan for how they are going to manage them.

Cesta says, "The emergency department staff should know that the hospital can't continue admitting every patient who shows up if they don't meet inpatient criteria. We have to work together to find alternatives to hospitalization."


For more information contact:

  • Toni Cesta, RN, PhD, FAAN, Senior Vice President, Operational Efficiency and Capacity Management, Lutheran Medical Center, Brooklyn, NY. E-mail: tcesta@lmcmc.com.
  • Brenda Keeling, RN, CPHQ, CPUR, President of Patient Response, Durant, OK. E-mail: brenda@patient-response.com.
  • Joanna Malcolm, RN, CCM, BSN, Senior Consultant, Pershing, Yoakley & Associates, Atlanta. E-mail: JMalcolm@pyapc.com.