Sloppy documentation costs millions; pathways can save your bacon
Sloppy documentation costs millions; pathways can save your bacon
Case managers take lead in salvaging denied charges
Physicians at Sinai Hospital in Baltimore hated the hospital’s duplicative and user-unfriendly documentation processes. But the hospital was losing millions each year in denied claims for under-documented cases. Something had to give.
Sinai lost $4 million to denied claims in 1996. And Sinai is not alone. Hospitals across the country are losing their shirts as a result of poor physician documentation in the medical record. The irony is that, in most cases, fixing the problem would be simple if physicians could just be coaxed to document properly.
Sooner a camel through the eye of a needle, you say, but Sinai found a solution. Now the hospital has a good chance to save millions it formerly lost because its processes made getting the right information in the right place too difficult.
Sinai’s problems arose with the creation of its critical pathways for total abdominal hysterectomy and lumbar laminectomy, says Karen Sweeney, RN, director of clinical resources management at Sinai. Many staff members and physicians saw the new pathways as merely another form to fill out.
"Now they had two places to document: on the pathway and on the routine tool," says Sweeney. "What we were finding was that often the pathway was sitting out there with nothing on it no documentation because people didn’t want to document in two different places."
To make matters worse, on July 1, 1996, Blue Cross of Maryland began strictly enforcing Chicago-based Milliman & Robertson’s (M&R) guidelines for total abdominal hysterectomy, which call for a two-day length of stay. When Sinai wrote its hysterectomy pathway to comply with those guidelines, physicians found it "a bitter pill to take," says Sweeney, who notes that the typical length of stay for that procedure has been three to four days in Maryland.
Physicians simply refused to place their patients on the two-day pathway or to document explicitly why patients were kept in the hospital extra days. As a result, Sinai experienced a flood of third-day claims denials, as did many other Maryland hospitals.
"So I’m in this dilemma," says Sweeney. "I can lengthen [the pathway] and make it a three-day path and get better compliance in using it, but then I’m not solving the problem with the denials. I’m still going to get denied."
In the first quarter of 1996, Blue Cross of Maryland denied 2% of inpatient days at Sinai. By the fourth quarter, that figure had more than tripled, to 7.25%. Even more troubling was the fact that only about 10% of patients undergoing total abdominal hysterectomy at Sinai were being released within two days a full 60% lower than what Blue Cross expects.
Sinai isn’t the only Maryland hospital struggling to meet the M&R guidelines. According to a state database of hospitals, only one hospital, Anne Arundel Community Hospital in Annapolis, has achieved 70% compliance. Most hover around 30%.
The problem is that physicians receive no direct penalty for keeping patients in the hospital longer than the guidelines dictate, says Sweeney. "The hospital gets denied that extra day, but the physician still gets his full fee, so he has no incentive to move the patient home earlier. Maybe they think there’s a reason that they’re justified, but they don’t put it in the chart. We go to defend the day, but if they don’t have good documentation, then we can’t appeal and we just eat the day."
Case managers must identify deficiencies
Sinai’s situation is typical of many institutions in which physicians have not been sufficiently educated about the consequences of poor documentation, says Susan Goodwin, RN, MS, CPHQ, director of quality management at Columbia/ HCA in Nashville, TN.
"Most third-party payers look at the clinical situation of the patient to determine whether a particular procedure is clinically justified," says Goodwin. "Oftentimes, organizations get into trouble with denials because the physicians have not completely documented the clinical rationale or justification for the procedure. And with that documentation lacking, the third-party payers are compelled to deny the case."
The problem is as old as Medicare itself, says Judy Homa-Lowry, RN, BS, CPHQ, director of quality improvement at the Delta Group in Greenville, SC, and consulting editor of Hospital Case Management. "At its inception, it was felt that hospitals control physician behavior," she says. "Instead of putting the onus on the person who has the most control over the resources that a patient’s going to get, Medicare put the onus on the hospital, and it’s been a source of frustration all along."
Homa-Lowry adds that when she’s examined the reasons for claims denials, she’s found a common pattern of poor documentation. "The indications were not listed along with the objective and subjective symptoms to justify the need for additional resources. Maybe they just described pain or congestion but not how long it had lasted, what the patient had tried to do about it. Or they didn’t include a thorough assessment of how long the patient had experienced pain or what things they had tried to do to relieve the pain."
When Homa-Lowry performs an open chart review, she typically works "back to front," looking first at the patient’s demographics, then at the laboratory values and other tests. "Then I flip to the front and look at the orders and plan of care," she says. Finally, she examines the documentation to see if it integrates and supports what’s contained in the medical record.
"I have done open chart reviews where there may be lab values or tests or signs of symptoms with the patient that are not consistently addressed among all the practitioners," says Homa-Lowry. "Or there may not be a consistent plan of care as to what to do about them. And if you’re in a position where you’re trying to justify treatment, it’s very difficult."
Given the pervasiveness of such problems, it’s crucial that case managers be diligent in performing internal utilization review and making determinations regarding the medical appropriateness of both hospitalization and resources used in the care of the patient, says Goodwin. "Case managers are in a position to identify the deficiencies or lack of information that’s in the documentation," she says. "Often, they can serve to notify physicians of what’s missing and coach them to do better documentation in the medical record."
Hook’ physicians into the pathway
One way Sinai Hospital is tackling its documentation problems is to eliminate redundant documentation whenever possible, says Sweeney. "We have been faced with the challenge of trying to create these pathways as part of the documentation tool, either by replacing something else or documenting by exception not by creating another layer."
One tactic Sweeney is using to boost physicians’ use of the total abdominal hysterectomy pathway is to fold into it such information as vital signs, intake and output, and patient assessments. "That replaces quite a few pieces of paper that used to be in the chart," she says. Sweeney adds that, because physicians monitor such information closely, having it in the pathway forces them to look at the path on a daily basis.
"We have struggled with physicians accepting the pathway as a useful tool," says Sweeney. "If it doesn’t really draw them, and they don’t need to go look at it to see something about the patient, how do you get them to look at it? We’re using [patient information] as a hook to get them to the document," she says.
At Anne Arundel Community Hospital, which leads Maryland in complying with Blue Cross’s M&R guidelines for total abdominal hysterectomy, the case manager for women’s services routinely counsels both patients and physicians on the importance of compliance.
"She may say to the patient, Your insurance provider pays only for 24 hours. If you stay another day, then you may be held financially responsible for that extra day,’" says Karen Petticord, RNC, PhD, clinical leader for women’s services at Anne Arundel. "She advises the physician on that, and usually the patient will choose to go home that day."
If a physician is keeping a patient for an extra day because of a suspected infection, the case manager talks to him or her about what must be documented within the chart to avoid a denied claim. Petticord adds that her job has been made easier by the fact that case management has "100% support" from the chief of service.
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