Case Management and The Revenue Cycle

1. Case Management and The Revenue Cycle AAHAM Thursday, May 14, 2009

2. Purpose of this Case Study • An assessment was performed to identify opportunities for improvement in the Revenue Cycle, focusing on case management. • Findings and recommendations address areas of improvement that could impact revenue capture, compliance, and reduce RAC denials.

3. MEDICAL MANAGEMENT MEDICAL RECORD & CODING CHARGE CAPTURE & ENTRY CLAIMS SUBMISSION REGISTRATION & POS CASH COLLECTIONS THIRD PARTY FOLLOW-UP FINANCIAL COUNSELING PAYMENT POSTING INSURANCE VERIFICATION REJECTION PROCESSING DENIAL & APPEAL MANAGEMENT PRE-REG & PRE-CERT CONTRACT MANAGEMENT SCHEDULING What is Revenue Cycle? CDM Metrics & KPIs FOCUS AREA Regulatory Compliance EDI-capability

4. Assessment Conducted over 4 to 6 days, consisting of: • Interviews • What have you inherited that may not belong in your department? • Observations • Chart review • Data Analysis

5. Overview Departments involved in interviews • Registration/Patient Access • Case Management • Social Work • Utilization Management • Denials Management • Observation Unit • Health Information Management

6. Registration Findings • Staff require orders prior to procedures • Staff do not always ask to see insurance cards and identification • Inefficient communication between patient access and utilization Recommendations • Implement a quality audit for registration and insurance verification • Involve patient access in the weekly case management meetings to address authorization issues • Patient access and utilization review staff need to consistently utilize work lists provided by the system to ensure information is shared between departments

7. Denial Management Findings • Medicaid denials are appealed by an LPN in case management • All other denials are reviewed in the business office by non-clinical staff Recommendations • All denials reviewed by same area, reporting to patient access • All clinical denials reviewed by a nurse • Enhance denial tracking by using a common work list with all denials in process and capturing denial reasons to uncover trends

8. Utilization Review Findings • UR staff each have their own daily work flow; however, the process is similar enough to allow staff to cover for each other • Process is paper driven and requires a number of manual steps • UR staff do not use the provided system for work lists Recommendations • Define work flow and processes • Evaluate staffing plan to promote teamwork with CM • Provide feedback on denial trends to UR staff

9. Case Management Findings • Documentation process is inconsistent for case management, and forms are ineffective • Documentation does not always stay with the patient’s chart • There is no defined or consistent work flow process • Staff lack tools required for their jobs: text pagers/cell phones, printers, fax machines • The Important Message from Medicare and Choice letters are not provided to patients on a consistent basis

10. Case Management Findings (continued) • No formal discharge rounds or long-stay patient meetings currently being conducted • Tasks are assigned by discipline (SW versus RN), which creates confusion for patients, hospital staff, and amongst themselves • No physician advisor/champion to support the department in difficult physician situations or to appeal denials • Nursing home referral process is disjointed, involving various departments

11. Case Managers Findings • Case Managers lack a consistent daily work flow • Most try to see Observation patients first • Reactive versus proactive • Case Manager carrying 30-50 patients a day • Limited direct communication with physicians • Limited insight into financial impact of case management

12. Social Workers Findings • Social workers receive unnecessary referrals as a result of limited patient screening performed by nursing staff • Confusion regarding which tasks require a social worker and which belong to case managers • Social workers spend a significant amount of their time on nursing home placements

13. Case Management Models

14. Model Comparison

15. Choosing the Right Model • FTEs will depend on hospital services • Denial resolution falls with front or back end regardless of model utilized • Caseloads • 3:3 40-50s • 3:1 22-25 • Hospital culture • Compliant and revenue-conscience

16. Recommendations New staffing model • Caseloads 22-25 based on floor assignment • 2-in-1 model • Nursing home placement coordinator • Gatekeeper 24/7 • Cross training is key to success • New orientation plan

17. Case Manager/Social Work Recommendations • Move entire Case Management department to the CFO • Weekly revenue cycle meetings • Registration/Patient Access Supervisor • Registration/BO Director • CM Director • HIM Director • Coding Supervisor • Charge Master leader • Director Revenue Cycle • Representative negotiating managed care contracts • CFO

18. Recommendations Implement weekly “long” stay/high dollar meeting • Goal: review patients with LOS>5 days; charges higher than $50,000; and all self-pay patients Attendees • Case Managers/Social Workers/Utilization Review staff • Patient Access • HIM/ coding • Physician – hospitalist group • Physician advisor or CMO • Nursing • Financial counselor

19. Meeting Process • Distribute list 24 hours ahead of meeting • Schedule for each Case Manager (e.g., 3-3:10 Mary) • Script expectations • Basic clinical, Days authorized, Days left for Medicare, Discharge plan, Problems • Physician issues • Compliments to be shared • Follow-up on compliments

20. Sample Patient Report • Patient Jon Doe admitted 7 days ago for sudden onset confusion • My discharge plan is… • I faxed clinicals yesterday and have 3 more days authorized • Report for tracking: Supervisor works it that AM and knows who is behind • Dr. Smith seems to be dragging out the stay • No family support • I’d like to thank the PT that saw him yesterday, she was very patient (specifics)

21. Tools Implemented • Defined work flow and updated policies and procedures • Improved documentation with customized forms to assess risk and plan for placement • Defined which case management documents become a permanent part of the chart and are scanned promptly • Provided tools like cell phones and laptops with wireless access • Trained staff to use Interqual criteria to document medical necessity

22. InterQual • InterQual (IQ) criteria is a trademarked tool provided by McKesson Health Solutions • IQ is the preferred tool used by the Centers for Medicare and Medicaid Services and most RAC audits • CMS requires hospitals to monitor and document medical necessity to assure compliance • Methods • IQ books • Software purchased from McKesson • Case Management software that includes IQ within its product

23. Level of Care Definitions Category or setting based on the clinical picture when patient is admitted to the hospital and/or when patient reaches clinical stability at one level. • Observation: onset last 24 hours, reasonable expectation that duration of assessment is 6-24 hours, assessment/medications unresponsive for at least 4 hours ER treatment, psychiatric crisis intervention • Acute: onset within one week, medications requiring monitoring q4-8 hours, IV medications, post critical care, post vent wean • Intermediate: onset within last 24 hours, medications requiring monitoring at least 2-4 hours, hemodynamically stable, telemetry, neuro assessment, post-op trauma • Critical: reasonable expectation for patient to stabilize with high-tech critical care, hemodynamically unstable, medication monitoring q1-2 hours, acute intubation, etc • Levels continue with LTAC, Acute rehab, sub-acute rehab, SNF, Home Care, home

24. Definitions • Severity of Illness (SI) criteria consists of objective, clinical indicators of illness including chronic illness or co-morbidities, which focus on an individual patient’s clinical presentation rather than the diagnosis • Intensity of Service (IS) criteria consists of monitoring and therapeutic services, singularly or in combination, that can only be administered at a specific level of care • Discharge Screens (DS) are organized by the levels of care subsets and provide objective, clinical indicators to determine if the patient has reached the level of clinical stability appropriate for a safe transfer to a different level of care

25. Review Process • Pre-admission review (Acute) • Admission review (Acute or Observation) • Continued stay review (Acute or Observation) • Cannot go backwards (e.g., acute back to observation) • Discharge review • Gatekeeper or case manager to perform IQ reviews • Always start with acute care section to see if criteria is met • Observation status should be used if case does not meet acute criteria

26. Discharge Review • Performed when IS not met or on discharge • Clinical disagreement arises • Supervisor-level review • Attending physician conversation • Physician Advisor • Patient refuses to discharge • Physician support • Hospital Inpatient Notification of Non-payment

27. Observation Process Findings • Observation versus Inpatient status determined by physician recommendation upon admission – UM review for clinical support of their decision • Presence of the order is checked after discharge unless CM happens to be reviewing the chart • If the order is unclear or missing, CM calls the physician for a clarification order • Continued stay reviews are completed but not retained in the patient record • Poorly understood process by all involved

28. Observation Process Recommendations • Implement 24/7 gatekeeper role to recommend status on all patients entering the hospital at all access points • Order present • Charges entered • Case managed • Change billing to hourly

29. Gatekeeper Role: Overview • Responsible for patients needing a bed: inpatient, observation, ED, L&D, etc. • Ensures that a status order is in all records • First to know of requests for beds to allow for immediate assessment of status, then calls House Supervisor • Logistics • Two or more FTEs to cover at least 12 hours a day, 7 days a week • RNs preferred, with previous Utilization Review Experience • Laptop needed for mobility around hospital

30. Observation Responsibilities • Entering OBS hours with appropriate start and stop times • Run OBS list twice a day • Visit floor to assess OBS patient progress toward discharge • Perform usual CM tasks to manage these patients, including discharge planning • Upon discharge or conversion to inpatient, enter order and enter exact observation hours into system

31. Results • Improved compliance, with an appropriate level of care assigned within 24 hours of admission and with a corresponding order present in the chart • Improved revenue capture due to proper procedures in place at beginning of patient stay • Reduced LOS with proactive planning for discharge and interdepartmental meetings on long stay/high dollar cases • Reduced RAC denials

32. Impact on RAC Audit • Using InterQual criteria to determined the correct level of care will establish medical necessity and ensure that an appropriate order is in the chart within 24 hours of admission. • Assigning an appropriate patient status prevents one day inpatient stays, which have been targeted for RAC. • Continued stay reviews ensure that a patient meets the Intensity of Service requirement and are performed every three days to prevent an unnecessarily extended length of stay. • If there is no documentation in the chart to support the level of care chosen by the physician, these continued stay reviews may prompt improved clinical documentation.