Physician-case manager team cuts LOS, denials
Physician-case manager team cuts LOS, denials
Collaborative effort focuses on top 10 DRGs
By working as a team, the physician advisor and case management staff at Mercy Medical Center in Canton, OH, have decreased Medicare length of stay, cut managed care denials dramatically, and made physicians aware of the cost to the hospital of inpatient services that could be done on the outpatient side.
As a result of their initiatives, Medicare length of stay has decreased from 6.83 days in 1998 to 5.07 days in 2004. The hospital’s denials consistently have been below 2% since 2001 and were at 0.8% in 2004.
The managers of case management and the director of quality management meet once a week with David L. Gormsen, DO, FACEP, chief medical officer and physician advisor to case management, examining the hospital’s top 10 DRGS and focusing on the ones with the highest cost or length of stay.
They have developed physician report cards, comparing lengths of stay for patients in the hospital’s top 10 DRGs and comparing the hospital’s length of stay to benchmarks.
"We looked at why the length of stay was higher for some patients, such as were we having difficulty getting tests conducted or whether treatments were being ordered in a timely manner. Then we developed strategies to reduce the length of stay," says Paula Benson, RN, BS, manager of case management.
In one instance, a physician’s patients had an extremely high length of stay in one DRG compared to his colleagues’ patients. When Gormsen talked to him, he argued that his patients were sicker. The team reviewed the charts for his patient and concluded he was right — the patients were indeed sicker and belonged in a different DRG. His issues were lack of appropriate documentation to support the appropriate DRG.
In addition to focusing on individual cases, the team looks at educational opportunities for the attending physicians, such as inpatient MRIs and gastrointestinal (GI) work-ups that are not appropriate as an inpatient treatment.
For instance, the team focused on GI work-up at the end of chest pain observation.
"We met with the physicians to educate them that this is something that is not reimbursed and something that clearly could be done on an outpatient basis," Benson says.
When the case managers encounter an order for a procedure that can be done on an outpatient basis, they contact Gormsen, who calls the attending physician and suggests ordering the procedure as an outpatient test.
"One case may not make a difference, but they do add up and increase the overall length of stay," he says.
The case management department has worked with the finance department to put a dollar value on some of the most common procedures performed in the hospital that could be done on an outpatient basis.
"This has been the biggest eye opener for physicians. Any time you can save a lot of money, it’s become very important," Gormsen says.
For instance, at Mercy Medical Center, performing an MRI on an outpatient basis instead of as an inpatient procedure saves $700.
"Major hospitals perform 100 or more MRIs each month on an inpatient basis. If they can do half as outpatients, they can save hundreds of thousands of dollars," Gormsen reports.
Physicians need to understand that if they do what is appropriate for their patients, it can add a lot of dollars to the hospital bottom line, he points out.
"If they help the hospital save that money, we can get them the state-of-the-art equipment they want, get the floors renovated, and make other capital improvements to help make their jobs easier," Gormsen explains.
Once a month, Benson and her staff create a "DRG of the Month" poster that is posted throughout the hospital to help focus staff’s attention on best practices and recommended care for that particular diagnosis.
The posters list the hospital’s length of stay versus the mean length of stay, the hospital’s reimbursement vs. cost, and helpful hints for physicians on timely and appropriate care. For instance, the congestive heart failure DRG of the Month poster included:
- Are your patients on the pathway for congestive heart failure?
- Are they compliant with their treatment plan, or do they need support after discharge?
- Was the congestive heart failure coordinator involved in their discharge plan?
- If there was a consultation, was it ordered in a timely manner?
- Were comorbidities taken into account when the treatment plan was developed?
The team has promoted care plans for pneumonia patients that include getting patients started on IV antibiotics in a timely manner, resulting in a significant decrease in pneumonia lengths of stay.
With Gormsen’s help, the team has been able to dramatically increase physician participation in appeals of denials.
"We don’t have that many cases denied, but the chance of getting the denial reversed goes up if the attending physician gets directly involved in the appeal," Benson says.
When a treatment is denied, the case managers contact Gormsen, who enlists the help of the attending physician in the appeal.
They send letters of appreciation with a small gift certificate attached when the attending physicians come through for the team by calling the insurance company’s medical letter or writing a letter if a denial for reimbursement is being appealed.
The hospital’s case managers are assigned by unit and by the type of coverage a patient has. Three case managers handle all the managed care patients. There are 4.5 FTE case managers who coordinate care for Medicare, Medicaid, and self-pay patients. They conduct an initial assessment and find out the discharge needs or barriers to discharge. If patients need more follow-up and intensive discharge planning, the case managers refer them to the discharge planners. The discharge planners are all social workers with the exception of one LPN in that role.
This year, the hospital has assigned a case manager to the medical teaching service, helping the residents within the hospital better understand case management and length of stay. The case manager rounds with them every day and educates them about the goals of case management.
"They become a team right from the start. The residents start to understand how important they are in helping case management and the hospital achieve our goals," Gormsen says.
(For more information, contact Paula Benson, RN, BS, at [email protected].)
By working as a team, the physician advisor and case management staff at Mercy Medical Center in Canton, OH, have decreased Medicare length of stay, cut managed care denials dramatically, and made physicians aware of the cost to the hospital of inpatient services that could be done on the outpatient side.Subscribe Now for Access
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