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At Saint Francis Hospital in Hartford, CT, the revenue cycle team is a strong partner of case management, reports Beth A. Greig, RN, MSN, MBA, ACM, director of case management, healthcare value, and efficiency at the 617-bed hospital.
“We meet on a regular basis with the revenue cycle team and work very closely to make improvement in our processes,” Greig says.
Saint Francis has case managers in the ED who conduct utilization review and work with the physicians on patient status and social workers who support patients with community needs. On the inpatient side, the case managers are responsible for care progression and transition planning. There are three utilization management nurses who are assigned by payer and assisted by a three-person support staff. The department has a dedicated team of physician advisors who are on site and available to assist the case managers and utilization review nurses, Greig says.
Case management representatives attend weekly complex case meetings and bi-weekly denials meetings with representatives from the revenue cycle team. In addition, the utilization management staff works closely with patient access and billing to ensure that the case is paid at the right level of care. The utilization management nurses also work with the benefit specialists to clarify insurance verification and to make sure authorization has been obtained for elective cases.
“We recognize that care progression and length of stay are revenue issues. We want to be as efficient as we can in managing length of stay so the hospital can be paid appropriately for the services we provide. Our department makes sure we have the right level of care for each patient when they were admitted and that we follow the rules for each payer to maximize reimbursement. Then we track any trends in denials and look for ways to improve,” says Caroline Segovia-Marquez, RN, BSN, MBA, ACM, RN manager for case management. (For a look at the hospital’s initiative that cut length of stay by about half a day, see related article later in this issue.)
The weekly complex case meetings are attended by the director of patient accounts, the manager for financial counseling, the social work manager for case management, the RN manager for case management, and the case management physician advisor. The meetings are led by the social work manager for case management.
Complex cases are identified in weekly high length-of-stay meetings during which the case managers and social workers present all cases with a length of stay of four days or more to a team led by the social work manager for case management. Appropriate cases are escalated to the complex case meetings.
During complex case meetings, the team focuses on patients with complex medical and social needs who have no payer source. They discuss what is happening clinically with the patient, what barriers are to discharge, and brainstorm ways to move the patient through the continuum, says Suzanne Sullivan, LCSW, ACM, social work manager for case management.
Funding is often a barrier to discharge, she adds. Patients may be undocumented immigrants, people who are homeless, or patients who have exhausted their Medicare skilled nursing benefit but still need that level of care.
“The meetings help us look at all the options for moving the case along early in the stay. If we didn’t take a proactive approach to these patients, they might have an extended stay,” Sullivan says. “We look at whether patients with no funding would qualify for Medicaid or assistance from a charitable organization or community agency. When the patients need care that can be provided in another venue, we discuss how to share the risk with other related entities and get the patients the care they need.”
The following are some solutions the team developed:
The team continuously works with financial counseling to prioritize cases that meet the eligibility requirements for Medicaid and assist the patients in applying. “This supports not only payment for hospitalization but also supports the services needed post-discharge,” Greig says.
A denials team, including the director of patient accounts, RN manager for case management, patient accounts denials manager, manager for patient access, and the case management physician advisor, meets biweekly. The team reviews the denials list by payer and type, looking for trends and areas for improvement.
For example, the team found instances where patient access did not correctly identify the type of Medicare payer — traditional Medicare or Medicare Advantage — and the receiving facility was denied the first day of care. The Medicare Advantage payer was not notified to authorize the day as required.
“For case management staff arranging for a transition to a skilled nursing facility, having this information is significant because the benefits and network of providers are very different for these types of plans,” Segovia-Marquez says.
Based on the team’s findings, the director of patient access re-educated the staff on how to determine the correct type of Medicare plan, she adds.
The case management team constantly analyzes trends on a case-by-case basis and takes steps to make changes that will ensure the hospital is paid appropriately.
For instance, the team reviews an electronic list of reports of Medicare short stay inpatients to determine if the patient meets Medicare rules for inpatient status. They look at whether the patient qualified through the benchmark criteria, had a procedure on the Medicare Inpatient Only list, or experienced an unexpected recovery. “Physician advisors participate in the final determination around these cases. Review of these patients is important from a revenue cycle perspective to make sure the organization is billing appropriately and is compliant with Medicare regulations. This process also helps to minimize the hospital risk around payer audits,” Greig says.
The utilization management case managers review the cases of observation patients frequently throughout the day. An electronic work queue alerts the staff of all patients in the hospital under observation status, along with their length of stay on an hourly basis. The case manager proactively identifies and acts on cases that can be promoted to inpatient status.
“If we find that one provider consistently places patients in the wrong status, we provide education through our physician advisors,” Segovia-Marquez says.
“Constant vigilance around this process is an important activity that assists the revenue cycle team and the hospital in ensuring that the organization is paid for the care given,” Greig 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.