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

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.

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

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

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

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

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

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

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

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

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

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

Case Management Models Roles: People 3:3 Model2:1 Model3:1 Model 1. Social Workers (SW) Discharge Planners Psychosocial Needs 2. Utilization Management (UM) RN Insurance Management Other 3. Case Managers (CM) Nurses Models within CM assignment varies Unit Physician Payer Disease Management Two versions 1.UM/CM (2) with SW on own 2.CM/SW (2) with UM on own CM assignment varied as in 3:3 Unit Physician Payer Disease Management CM/UM/SW roles in one person Assignments Unit Physician Payer Disease Management

Model Comparison ModelAdvantagesDisadvantages 3:3Individual Expertise Easiest to implement 3 people in chart Poor productivity Confusing to customers Confusing to patients Difficult case sharing Hand-off mishaps More staff to manage 2:1Works well in certain hospitals Expertise driven Promotes teamwork Good transition to 3:1 2 people in chart Confusing to customers Difficult case sharing Hand-off mishaps 3:11 person in chart Clear assignment for customers Complete start to finish care Fewer staff to manage Comprehensive understanding of all aspects has positive revenue implications Only for high-functioning hospitals Requires more training than others

Choosing the Right Model  FTEs will depend on hospital services  Denial resolution falls with front or back end regardless of model utilized  Caseloads  3: s  3:  Hospital culture  Compliant and revenue-conscience

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

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

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

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

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)

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

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

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. 1. 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 2. Acute: onset within one week, medications requiring monitoring q4-8 hours, IV medications, post critical care, post vent wean 3. Intermediate: onset within last 24 hours, medications requiring monitoring at least 2-4 hours, hemodynamically stable, telemetry, neuro assessment, post-op trauma 4. Critical: reasonable expectation for patient to stabilize with high-tech critical care, hemodynamically unstable, medication monitoring q1-2 hours, acute intubation, etc 5. Levels continue with LTAC, Acute rehab, sub-acute rehab, SNF, Home Care, home

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

Review Process 1. Pre-admission review (Acute) 2. Admission review (Acute or Observation) 3. Continued stay review (Acute or Observation)  Cannot go backwards (e.g., acute back to observation) 4. 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

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

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

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

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

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

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

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.