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Case management directors should take a proactive approach to managing denials and monitor their short inpatient stays, watch for trends, and prevent inappropriate short-stay admissions, says Beverly Cunningham, RN, MS, consultant and partner at Oklahoma-based Case Management Concepts.
“The oversight of short inpatient stays is not going to go away. The Office of Inspector General [OIG] spent a lot of time and effort studying the medical necessity for short stays, and the audits are going to continue. CMS requires that hospitals perform self-audits of short stays, and case management leadership should be following the requirement,” she adds.
A report issued in December by OIG concluded that hospitals are billing for many short inpatient stays that are inappropriate.
The OIG report included a list of the top 10 potentially inappropriate short inpatient stays, and the top 10 long outpatient stays. Five of the items — chest pain, digestive disorders, fainting, coronary stent insertion, and circulatory disorders — are on both lists, Cunningham says. (For more on the lists, see the box in this issue.)
“Those are just giveaway denials that could be corrected by self-auditing,” she says.
Case management leadership should read the OIG report and share a summary of the study with the utilization management committee and physician advisor, Cunningham suggests.
Case management leadership should compare the short stays of 2013 and 2014 (the years analyzed by the OIG) to the short stays in 2015 and 2016 to determine if the number is increasing, she says.
In addition, she suggests, case management leaders should institute a self-audit process to review short-stay cases on a regular and timely basis. The review group could include the utilization review committee, or the case management physician advisor and the hospitalist group medical director. “Only a physician can deny a Medicare stay. Case managers can make recommendations, but a physician has to sign off on it,” she says.
Cunningham recommends asking the business office to hold the bills for the short inpatient stays until the self-audits are completed. “The business office doesn’t like holding the bill, but they dislike having to rebill even more,” she says.
She reports that one hospital client began the self-audits after their Quality Improvement Organization (QIO) denied 80% of the claims it reviewed during the first rounds of audits. Most of the denials were for documentation. When the QIO audited again, all of the claims were upheld, she says.
The hospital team conducts the self-audit of short stays the week after patients are discharged. Every Tuesday, the appeals coordinators review all short stays discharged the week before and meet with their physician advisor and the hospitalist team’s medical director on Friday to discuss them.
“The medical director of the hospitalist group sends out emails each week, as cases are reviewed, to the hospitalist who treated each patient identified during the self-audit. Since the patient had been discharged only a week earlier, the physician remembers the circumstances and can make changes in his or her practices based on the feedback. This wouldn’t happen if the audit was conducted two months later,” she says.
When the coordinators began the process they had a lot of self-denials, but as the hospitalists changed their practices based on feedback, they’re down to only a few each week, she says.
“We know that good processes can make a huge difference. This is an easy process once it is put in place. It takes time to get it going, but then it works like a dream,” she says.
In addition to managing denials as they occur, hospital leadership should look for trends, provide education and training, and establish processes to prevent future denials, says Debra Primeau, MA, RHIA, FAHIMA, president of Primeau Consulting Group in Torrance, CA.
She suggests creating an interdisciplinary denials management team to analyze the denials and establish changes to minimize or eliminate future denials. The team should include case managers, physicians, representatives from coding, billing, and patient registration.
“Healthcare providers are becoming data-rich, but most are not using the information to minimize future risk. In addition to collecting the data, hospitals need to do something with it,” she says.
She recommends beginning by ensuring the data being collected are accurate and that all areas of the hospital collecting data in different information technology systems are defining the data the same way. This way, people will trust the data they are using and feel comfortable about its accuracy.
Financial Disclosure: Author Mary Booth Thomas, Editor Jill Drachenberg, Editor Dana Spector, and Digital Publications Coordinator Journey Roberts 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.