Compile data to make your case to administration

Show CMs affect patient flow, bottom line

It will take well-organized data to show your hospital administration how case managers can affect patient flow and to justify additional staff to focus on the effort, says Toni Cesta, RN, PhD, FAAN, vice president, patient flow optimization for the North Shore-Long Island Jewish Health System and health care consultant and partner in Case Management Concepts LLC.

"Data can be very compelling, but they have to be presented to the administration in a form they can relate to," she adds.

The most important thing that case managers can do to improve patient flow is to track and trend the barriers to moving patients through the hospital and implement performance improvement initiatives, adds Brenda Keeling, RN, CPHQ, CPUR, president and owner of Patient Response, a Milburn, OK, health care consulting firm.

This may mean putting case managers in the emergency department, increasing the hours that case managers cover the hospital, or hiring a full-time physician advisor to assist case management, she adds.

"The average cost for a patient day is about $1,200. Inappropriate admissions for which payment is denied or patient days that are denied because they no longer meet medical necessity can get costly for hospitals. If you can show how case managers can help avoid the denials, you can make your case," Keeling says.

Cesta worked with one hospital to conduct a retrospective analysis of patients who were admitted through the emergency department and whose entire stay was denied because they didn't meet admission criteria.

$3 million opportunity

The analysis revealed a $3 million annual opportunity to increase reimbursement by developing a process to ensure that patients admitted through the emergency department meet criteria.

Start by compiling information on admission denials — patients who were admitted but the hospital received no payment for the stay — Cesta recommends.

Drill down to find the reasons for the denial and how the patients were admitted in the first place.

Determine the average length of stay for patients whose stay was denied. Then tabulate the cost to the hospital for the denied care, which translates to how much money the hospital would have saved if the patient had been placed in observation or evaluated and sent home.

"Not only does the hospital lose money when the admission is denied, they take up a bed that could be occupied by patients whose cost of care would be reimbursed," Cesta says.

Look for the root cause

Look at your hospital's busiest times and determine how many hours the emergency department was on diversion and how many patients were admitted who were more appropriate for outpatient services, skilled nursing, or rehabilitation, Keeling suggests.

Look for the root cause for denials: Is it one specific carrier, one provider, one department, floor, or one case manager? And do a cost-benefit analysis of the financial side of impeded patient flow, she adds.

"Case managers tend to deal with denials from insurance companies because they know that's where the hospital's income is coming from, but they don't look at why there are denials," Keeling says.

Determine the reasons for denied days and attach a dollar figure to each cause, she suggests. Present the data in an informative manner, using charts and graphs, rather than anecdotal information, Keeling adds.

"People can instantly understand visual presentations. Showing a chart is far more effective than making a long, verbal presentation," she adds.

Use the data to make your case for more staff or for having a full-time physician advisor, Keeling says.

Physician advisor case

"A lot of hospitals don't have a physician advisor, or they have someone who works only part time. Case managers have to show how the physician advisor can help with throughput by intervening when a physician insists on admitting a patient who doesn't meet criteria or when discharges are stalled," she says.

If you have a part-time physician advisor, track the times that he or she intervened with the admitting physician and resolved the issue for the case manager.

Collect all the other potentially avoidable days and show how much it would have saved the hospital if there had been a physician advisor to intervene on just a percentage of them, she adds.

For instance, a patient is admitted with a high fever and put on IV antibiotics. The insurance company denies coverage for the last two days of care because the patient could have been converted to oral antibiotics and sent home.

"The case manager can document that he or she was unsuccessful in persuading the attending physician to send the patient home and show that if there had been a physician advisor to discuss the situation with the attending, the denial could have been avoided, saving the hospital a minimum of $2,400," she says.

Your data also can be used to gain support from the administration in dealing with issues that impede patient flow, she suggests.

For instance, the administration may not listen if you talk about how you can't get Dr. Smith to discharge his patients in a timely manner, but if you can present data that show that 80% of denials are Dr. Smith's patients, the administration will take notice.

"The administration has to have data in order to go head-to-head with a physician, particularly if he or she is one of the top admitters," she says.

In another scenario, if a piece of equipment, such as a CT scan machine, was broken, look at how many days were denied because patients were waiting for the service and add up the cost.

"The administration may think it would be expensive to get the machine fixed, but when that's compared with the cost of a lot of patients staying extra days, it's a bargain and it improves patient flow," she says.