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When case managers concentrate only on getting the patient status right up front and then review only selected patients and review them every few days, it’s likely to have a big effect on the financial health of the hospital, says Brian Pisarsky, RN, MHA, ACM, associate director of Emeryville, CA-based Berkeley Research Group.
“If case managers don’t manage the care of every patient every day, there is a potential for a longer stay and with many payers, it could have an adverse effect on the bottom line,” Pisarsky says.
In addition to ensuring appropriate reimbursement, it’s a matter of practicality to review every patient every day when appropriate, Pisarsky says. “Depending on the patient’s clinical condition these reviews can be done with less frequency, but reviewing the patient on day one and not reviewing them again during the entire stay is not the best practice and it definitely has financial implications,” he says.
Case managers should make sure while the patient is still in the hospital that the days of hospitalization are authorized, that any appeals are conducted concurrently, and that all of the contractual requirements of the payers are being followed, says Beverly Cunningham, RN, MS, consultant and partner at Oklahoma-based Case Management Concepts.
For instance, when a patient’s status changes from observation to inpatient, most commercial, managed Medicare and Medicaid payers require notification.
Concurrent denials management makes it imperative for case managers to have an effective internal physician advisor, Cunningham says.
For instance, a physician advisor can encourage the attending physician to participate in a concurrent appeal of a denial within the timeframe specified by the payer. If the denial is issued on Monday shortly before a new hospitalist team comes in, the incoming hospitalist may want to delay the denial until the first team returns, potentially missing the insurer’s deadline. That’s where an intervention by the physician advisor can be valuable, Cunningham says. (For more information about forging a relationship with physician advisors, see the June 2016 issue of Hospital Case Management.)
Case managers should conduct a discharge assessment and start working on a discharge plan for every patient within 24 hours of admission, Pisarsky says.
The proposed discharge planning guidelines CMS developed for the Medicare Conditions of Participation would require a discharge plan for many patients that in the past would not have required an intervention, Pisarsky points out.
“If Medicare requires it, most commercial plans are likely to adapt these requirements quickly. Timely discharge planning can prevent patients from spending extra days in the hospital, which benefits the insurer and the patient,” he adds.
After the discharge planning is complete, case managers should continue to manage every patient, Pisarsky says. “Don’t jump to the conclusion that patients with uncomplicated diagnoses don’t need case management. Just because the last 25 similar cases have been routine doesn’t mean that the next case will also be predictable,” Pisarsky says.
It’s not uncommon for patients to come in for a simple procedure and develop some issue that requires more treatment or post-discharge services, he says.
“For instance, a surgical patient may have unexpected complications and need to be placed in observation or admitted. Case managers need to manage those patients in real time, rather than coming in the next day after the hospital has provided 16 hours of free care to the patient because the status is wrong,” he says.
“The discharge plan for some patients may seem simple until the case manager finds out they are locked out of their apartment and now homeless, or there’s nobody to take them home. A routine patient can turn into an absolute financial disaster,” 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.