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Don't allow changes in status to bring denials
You must notify payer immediately
Previously, case managers at University of Louisville (KY) Hospital were assigned by service, and "they were all over the place," says Mary G. Lawson, BSN, MPA, director of admissions.
"Even in the best hospital, when trying to cohort patients, there is always one or two patients that may get assigned to a different floor because of bed availability," she explains. To avoid confusion, says Lawson, the case managers are assigned by floor instead of by service. "They now have the pulse of every single patient," she says. "Communication has improved. They create a bond with the floor nurse, and interdisciplinary rounds are being instituted."
Case managers immediately know when a patient goes from observation to inpatient status, and they will obtain the necessary authorization from the payer, says Lawson. If the claim is later denied, the appeal should be successful so long as there is adequate documentation, she adds. "We put a strict policy in place, and we have educated staff on this, on what to do when a patient is converted from outpatient to inpatient status," says Lawson. "We monitor the bed control system, and once that patient is converted, insurance is notified immediately."
These steps occur:
1. Bed management receives an order to change a patient from observation to an inpatient from the patient unit or physician.
2. Once the order is completed, the insurance company is notified of the admission.
3. Case management is notified of the authorization needed.
At times, case managers have to justify why an insurance company wasn't notified about a patient's admission, says Lawson. "It may be that a patient was in a motor vehicle collision and their wallet was left in the car, or the patient may be unconscious," she says. "In that case, it wouldn't be until the family comes that we are able to determine that they had insurance."