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If hospitals are doing only denials management and not avoiding denials up front, they’re already behind, says Beverly Cunningham, RN, MS, consultant and partner at Oklahoma-based Case Management Concepts.
“Hospitals have to start managing potential denials before admission or on admission, and this means that case managers should be involved in the revenue cycle from pre-admission to post-discharge denials management. Anybody who avoids denials during the pre-admission or admission process is an important part of the revenue cycle,” she says.
Case managers should cover all access points in the hospital — the ED, surgery, the transfer center, and direct admissions — to make sure the status is correct up front and insurance authorization is completed, says Brian Pisarsky, RN, MHA, ACM, associate director at Emeryville, CA-based Berkeley Research Group.
Smaller hospitals can combine the roles, Cunningham says. For instance, the ED case manager might function as the transfer center case manager or the access case manager. “All of these case managers should be denials management experts, and their responsibilities are to prevent denials up front,” she says.
It is the responsibility of case managers and multidisciplinary teams at all points of entry and on the unit to make sure the hospital is following the requirements of the insurance companies and getting approval at the specified times, Pisarsky adds.
When patients have scheduled surgery, are being transferred from another hospital, or admitted from the community, case managers should review the cases before patients arrive or as quickly as possible after admission to review medical necessity, appropriate status, and expected financial reimbursement, Pisarsky says.
At one time, pre-admissions responsibilities meant only that the patient access staff notified payers and obtained authorization for admissions, Cunningham says.
“That part is still their responsibility, but in today’s healthcare environment it is critical that we get the patient in the right level of care, and this means case managers need to be involved before the patient arrives at the hospital or at the time of admission for urgent and emergent admissions,” Cunningham says.
Case managers should be assigned to review orders of patients scheduled for surgery or those coming from the physician office and intervene if there are problems.
For instance, a surgeon may want to admit a patient who lives 100 miles away the day before surgery. In that case, the case manager can work on alternatives, such as arranging a hotel room for the patient. “If necessary, it would be cheaper for the hospital to pay for a hotel room rather than keep the patient overnight in a patient room when it won’t get paid for the first day of the stay,” she says.
The case manager could inform the family that insurance won’t cover the pre-surgical stay or, for Medicare patients, give them a pre-admission Hospital Issued Notice of Non-Coverage (HINN).
Perioperative case managers are critical to making sure patients are ready for surgery, that the discharge planning is done, and that patients are placed in the right level of care, Cunningham says.
Cunningham tells of an incident when a patient scheduled for same-day surgery told the case manager during a pre-surgery call that he was planning to drive himself home because he didn’t have a ride. The surgery was postponed until he could have someone accompany him and drive him home.
“If the case manager hadn’t called, the hospital would have had to keep the patient overnight without being reimbursed for the overnight stay in addition to the patient taking up a bed that would be occupied by a paying patient,” Cunningham says.
Before patients arrive for surgery, case managers should make sure patients are authorized for inpatient or outpatient procedures, Cunningham adds. “More HMOs are requiring pre-certification for outpatient procedures,” she says.
Perioperative case managers should make sure there is not an automatic plan to keep same-day surgery patients overnight, Pisarsky adds. Hospitals should have a process in place so that when Medicare beneficiaries have surgery, the case managers should check the inpatient-only list and make sure the order is correct prior to the procedure.
It’s important to screen all surgical and procedure patients for potential post-procedure complications before the patient comes in the door, even if it’s an outpatient procedure, Pisarsky says.
Pisarsky recommends working with the pre-admission testing area to make sure they ask appropriate questions, such as where the patients plan to go after surgery, how they are going to get there, and who will take care of them at home.
“Case managers may not be the ones to ask the questions, but the answers can alert them that they need to take a deeper look at a patient,” he says.
Large hospitals that receive a lot of transfers should have a case manager in the transfer center to triage transfer patients to make sure they meet admission criteria and are admitted in the right level of care, Cunningham says.
The transfer center case manager’s role should be to review the patients being transferred to ensure that the care they need cannot be provided at the transferring facility, whether the patient’s insurance will cover care at that hospital, and that they are placed in the right level of care. Patients transferred from an outlying ED would be accepted under the Emergency Medical Treatment and Labor Act (EMTALA), Cunningham adds.
For instance, a patient in a smaller hospital may be in the ICU, but that doesn’t necessarily mean they need to go directly to the ICU. The telemetry unit may be a more appropriate placement, Cunningham says. “Commercial payers or Medicare HMOs may agree that the patient meets inpatient criteria, but may deny the intensive care unit level of care,” she adds.
Medicare has specific rules around patient transfers, Pisarsky points out. If the patient needs to be in a higher level of care, such as the ICU, case managers should make sure the orders and the documentation in the medical record reflect it, he adds.
Make sure the hospital has a transfer agreement specifying that the transferring hospital will accept patients back once their treatment is complete, Pisarsky suggests.
Case managers in the emergency department have an essential role to play, Pisarsky says. They prevent denials by working with physicians to see that patients are in the right status and level of care. They can prevent admissions and readmissions by lining up post-discharge services and facilitating referrals to post-acute providers to prevent an acute care admission, and start the assessment process for patients who are being admitted. (For more information on ED case management, see the July 2016 issue of Hospital Case Management.)
Pisarsky recommends that case managers talk with the family while the patient is still in the ED, discuss the expected length of stay, and begin assessing for post-discharge needs.
“Many times, the initial chance case managers get to see family members is in the emergency department. Talking to family members before admission is the best way to get patients to the appropriate level of care as quickly as possible when they are ready to be discharged, and avoid keeping patients another day while the case managers play catch-up after the admission,” he says.
Managing Editor Jill Drachenberg, Associate Managing Editor Dana Spector, and Editor Mary Booth Thomas, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Nurse Planner Toni Cesta, PhD, RN, FAAN, Consulting Editor of Hospital Case Management, is a consultant with Case Management Concepts LLC.