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YOUR ECONOMIC IMPACT THROUGH CASE MANAGEMENT: UTILIZATION MANAGEMENT,
DENIALS AND RESOURCE MANAGEMENT
Toni G. Cesta, Ph.D., RN, FAANConsultant and Partner Case Management ConceptsNew York Office
And
Bev Cunningham, MS, RNVice President Resource ManagementMedical City Dallas HospitalPartners and ConsultantCase Management ConceptsDallas Office
The information provided in AHC Media Webinars does not, and is not intended to constitute medical or legal advice. Opinions, references and links provided by our speakers are provided for your convenience and do not represent our endorsement of such opinions, products or services.
Tuesday, August 12th, 2014
FACULTY
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Bev Cunningham, RN, MS is Vice President, Resource Management at Medical City Dallas Hospital. Her areas of responsibility include Case Management, Health Information Management, Clinical Documentation Integrity, Patient Access and Transplant Financial Services. Bev is a well-known speaker in the Case Management field. Involved in the development of case management for over twenty five years, her areas of expertise include denials management, patient flow and the role of the Case Manager and Social Worker in the Case Management process. She has served as a Commissioner on the Commission for Case Management Certification. Bev is also a partner and consultant in Case Management Concepts, a company that provides support to hospitals regarding effective Case Management model development and evaluation. Bev's publications include a chapter in CMSA's Core Curriculum for Case Management Certification and most recently, co-author of the book, Core Skills for Hospital Case Management. She is also on the advisory board for Hospital Case Management.
Toni G. Cesta, Ph.D., RN, FAAN is Partner and Healthcare Consultant in Case Management Concepts, LLC, a consulting company that assists institutions in designing, implementing and evaluating acute care and community case management models, new documentation systems, and other strategies for improving care and reducing cost. The author of eight books, and a frequently sought after speaker, lecturer and consultant,
Dr. Cesta is considered one of the primary thought leaders in the field of case management. Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management journal in which she shares insights and information on current issues and trends in case management. Prior to her current work as a case management consultant, Dr. Cesta was Senior Vice President – Operational Efficiency and Capacity Management at Lutheran Medical Center in Brooklyn, New York.
OBJECTIVES1. Review the role of contracting and payers in the
utilization management role.
2. Explain a successful tracking and reporting process for denials.
3. Discuss a process to identify opportunities to improve your resource management.
4. Explain new and revised case management standards, regulations, and laws put forth by CMS, TJC and the federal government.
5. Evaluate case management protocols and penalties.
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THE FOUR FUNCTIONS OF THE RN CASE MANAGER
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Utilization Management
Care Coordination
Discharge Planning
Resource Management
UTILIZATION MANAGEMENT:THE BASIC FOUNDATION OF CASE
MANAGEMENT
UTILIZATION MANAGEMENT DEFINITIONS
Utilization review: Reviewing medical necessity, appropriateness and efficiency of medical services and procedures provided
Utilization management: Analysis of medical necessity, appropriateness and efficiency of medical services and procedures provided………….and the coordination of such
Revenue cycle: All administrative and clinical functions that contribute to the capture, management and collection of patient service revenue. (Healthcare Finance Management Association Glossary)
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CMS RULES AND REGULATIONS RELATEDTO UTILIZATION MANAGEMENT
◦ Conditions of Participation requirements: 42 CFR Ch. IV (10‐1‐04 Edition 482.30) “The hospital must have in effect a utilization review plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid program”
Utilization management function UM Committee
◦ 2 Midnight Rule◦ Accurate IP order◦ Condition Code 44◦ Provider Liable◦ Advanced Beneficiary Notice of Noncoverage (ABN): Outpatient◦ Hospital Issued Notice of Noncoverage (HINN): notification to Medicare patients that services referred to in HINN are unlikely to be covered by Medicare
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ESSENTIAL CASE MANAGEMENT DEPARTMENT ACTIVITIES OF UTILIZATION MANAGEMENT◦ Document assessment findings and communicate to stakeholders◦ Identify appropriate level of care appropriateness ◦ Establish goals objectives and case management outcomes in collaboration with key stakeholders◦ Assure prior preauthorization of services◦ Review benefits of patient’s insurance policy◦ Ensure appropriate and accurate documentation◦ Assess opportunity for funding sources in private and public sector services
(Case Management Certification Commission)8
YOUR HOSPITAL REIMBURSEMENT Diagnosis Related Groups (DRG): case rate Per diem: payment for each day in hospital Percent of charges Carve‐out services: based on contract; usually for high cost services, such as implants
Pay for performance: reimbursement or reimbursement penalty based on clinical outcomes
Global payment/bundled payment: reimbursement for both facility, all levels of care (both IP and OP) physician services—most often seen in transplant in hospitals and the Accountable Care Organization (ACO) model
Stop loss: increase in payment after charge threshold met Outlier : increase in payment after specific combination thresholds met, such as both LOS and charges
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UTILIZATION MANAGEMENT BILLING
Status assignment (for billing)◦ Outpatient◦ Observation service◦ Inpatient
Level of care (for billing)◦ Medical/surgical◦ Intermediate◦ Critical care◦ NICU levels of care
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UTILIZATION MANAGEMENT REVIEWS BY RN CASE MANAGER Admission medical necessity
◦ Is patient sick enough to be admitted to the hospital?◦ Is patient receiving treatment at a level requiring admission to the hospital?
Continued stay medical necessity: ◦ Is the patient receiving treatment at a level that requires the patient to continue stay in hospital?
◦ Is the patient improving/responding to the treatment?◦ Is that medical necessity documented?
Discharge criteria: Is the patient meeting medical necessity (well enough) to transfer to next level of care (either in hospital or outside of hospital)?
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UTILIZATION MANAGEMENT IS NOT MANAGING THE PATIENT FROM THE
COMPUTER OR THE CHART
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GET THE STATUS AND LEVEL OF CARE ACCURATEON ADMISSION: Know All The Access
Points To Your Area Of Coverage ED Direct admission from physician office Outpatient sites in facility◦ Cath Lab◦ GI lab◦ Clinics◦ Therapies◦ Special procedures◦ Ambulatory Surgery Center◦ Same Day Surgery
Scheduled admission Transfer◦ From another facility◦ From another department in your facility
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APPROPRIATE UM DOCUMENTATION
Physician(s) Hospital staff: nursing and ancillary services Case Manager◦ Clinical notes in medical record Care coordination Discharge planning Counseling
◦ UM notes—not in medical record Medical necessity met, or not met Status Level of care Physician communication Payer communication Agreement or disagreement with any denial
◦ Frequency of reviews
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PHYSICIAN UTILIZATION MANAGEMENT DOCUMENTATION
Clinical picture must be documented, including any OP treatment related to admission
*Documentation show need for hospital services◦ At least two midnights or just one midnight?◦ Observation service if one midnight◦ Inpatient if at least two midnights
*Is there an appropriate admission order? *Is admission order authenticated before patient discharged?
* 2 midnight rule requirements 15
APPROPRIATE UM DOCUMENTATION
Sample documentation elements◦ Demographic information◦ Admission date◦ Estimated discharge date◦ Payer and payer contact information, including reference #◦ Admission medical necessity◦ Date of next scheduled review with medical necessity criteria◦ Pertinent lab, test results, care coordination information◦ Avoidable day/variance information◦ Physician advisor referrals
The role of the electronic system
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UM DOCUMENTATION SOURCES Automated care delivery documentation◦ Clinical paths◦ Order sets◦ Pay for performance evidence‐based plans of care
Documentation sources for medical necessity determination◦ Orders◦ Progress notes◦ Lab imaging or procedure reports◦ Ancillary service documentation, such as PT, pharmacy, respiratory care notes◦ Nursing documentation◦ Consultant documentation
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INCORPORATE UTILIZATION MANAGEMENT IN TO YOUR DAILY CASE MANAGEMENT ROUTINE
Effective Case Management
Care Coordination and Discharge Planning
Utilization Management
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A DAY IN THE LIFE OF A CASE MANAGER’S UTILIZATION MANAGEMENT ROLE
Automated daily report of patients◦ Name◦ Payer◦ Status: inpatient, observation service, outpatient in a bed◦ Hospital day or observation service hours◦ Physician(s)
Develop priority, based on unit or patients covered◦ Observation service Medicare: 2 midnight rule Non‐Medicare
◦ New admissions: best practice case managers review patients the day they are admitted
◦ Discharge planning Discharges planned for today Care coordination requirements Discharge planned for tomorrow
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UTILIZATION MANAGEMENT WITH PHYSICIANS
Review chart for medical necessity If patient in observation, allow time for lab/test results to be available
Discuss any Medicare patient with a one night stay for observation services
You cannot bill any payer for a status level that does not document medical necessity for the level of care for which you are billing
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A DAY IN THE CASE MANAGER’S UTILIZATION MANAGEMENT ROLE
New admit◦ Review order Is there an appropriate admission order? Does this order match your information system status?
◦ Does the documentation in the medical record meet criteria for order written?◦ Determine date for next scheduled review Follow hospital policy for frequency of reviews Use critical thinking skills to determine next review date Develop relationship with nursing and ancillary services so they notify you should patient clinical picture change
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A DAY IN THE CASE MANAGER’S UTILIZATION MANAGEMENT ROLE
New admit◦ Payer Confirm notification of payer Identify payer requirement for communication: Who to contact, when to make next contact and how to make contact
Is there a payer onsite case manager?◦ Discuss patient◦ Get commitment for status and level of care assigned
◦ Document review (not in medical record)
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A DAY IN THE CASE MANAGER’S UTILIZATION MANAGEMENT ROLE
Continued stay review ◦ Assess documentation from last review—has intensity of service changed?◦ Does the documentation in the medical record meet criteria for continued stay
◦ Does patient meet criteria for next level of care—either in hospital or post acute
◦ If criteria not met, discuss with physician; escalate appropriately◦ Determine date for next scheduled review◦ Payer Communicate with payer if appropriate Discuss discharge planning needs, if indicated Update review with on‐site case manager, if indicated Request return confirmation if communication is not person to person or over the phone
Assure notification if patient transitioned from observation to IP◦ Document review (not in medical record)
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A DAY IN THE CASE MANAGER’S UTILIZATION MANAGEMENT ROLE
Continued stay review for resource management◦ Utilization of services Overutilization Underutilization
◦ Clinical paths/protocols followed
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A DAY IN THE CASE MANAGER’S UTILIZATION MANAGEMENT ROLE
Discharge review ◦ Assure patient meets discharge criteria◦ Provide hand‐off communication In hospital Post acute
◦ Document review (not in medical record)◦ All accounts should be closed, but do not close UM record until payer communicates back regarding approval of days and level of care
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TIMELY AND APPROPRIATEESCATION OF MEDICAL NECESSITY
• Attending physician• Peer case manager
Level 1
• Supervisor• Physician Advisor• Attending physician
Level 2 • Supervisor• Physician Advisor• UM Committee
Level 3
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GOAL OF REVENUE CYCLE AND UTILIZATION MANAGMENT:To be paid for services rendered
GOAL OF CASE MANAGEMENT:To be the clinical business management department
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REVENUE CYCLEPatient admitted
Verification & notification
Clinicals called in: Patient Care delivered and care documented
Patient discharged
Bill dropped: Coding from documentation; account closed with all days authorized (or notification of non‐authorized days)
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REVENUE CYCLEPatient admitted
Verification & notification
Clinicals called in
Patient discharged
Bill dropped
WHERECAN
ERRORSOCCUR?
Before pt adm: Elective, HMO auths, OON, Uncovered benefits
At time of adm: Notification, Level of care, Med necessity
Incomplete informationLack of medical necessityNotification of change in level of care
•Incomplete information•Inaccurate coding
•Incorrect billing, Late billing•Never event or hospital acquired condition, resulting in payment penalty •Payer pays partial payment
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PAYER EXPECTATIONS OF OURUTILIZATION MANAGEMENT FUNCTION 24/7 services No delays Timely filing of claims Contract followed Timely and complete communication Compliance to regulations Appropriate billing status Documentation to support billing and coding Quality care
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UTILIZATION MANAGEMENT FOCUS AREAS FOR THOSE WHO REIMBURSE……
AND THEREFORE DENY Medicare◦ 1 and 2 day stays◦ 3 day stays for patients transferred to SNF◦ IP only procedures◦ Quality care
Medicaid◦ Patients <24 hours with IP order
Managed care (commercial, managed Medicare, managed Medicaid)◦ Technical issues◦ # IP days◦ Quality care◦ Observation rate
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DENIAL MANAGEMENT The process of monitoring and managing third‐party payer reimbursement from pre‐admission to post‐discharge. Includes:◦ Pre‐authorizations◦ Billing◦ Denials and appeals management Concurrent Retrospective◦ Appropriate care provided
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KEY FUNCTIONS OF DENIAL MANAGEMENT
Ensure clinical information in medical record is accurate and reflects care rendered to the patient
Ensure this information is provided, when necessary, to third‐party payer in timely manner and based on nationally established guidelines
Ensure patient is transitioned to next level of care as quickly as possible, once patient no longer meets clinical criteria for current level of care
Work closely with pre‐certification staff at front‐end and billing staff at back‐end
Appeal denials as necessary Do not appeal, just to appeal
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KEY FUNCTIONS OF DENIAL MANAGEMENT
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Best defense is a good offense. Prevent denials whenever possible!
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REVENUE CYCLESHARED ROLES
Verification of benefits‐‐Finance Pre‐Authorization – Finance Concurrent Review: Case Management Billing – Finance Appeals – Case Management and Finance
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DENIALS RELATED TO CASE MANAGEMENT
Lack of payment of entire bill that is charged to the payer due to medical necessity
Decrease in payment ◦ Carve out of days
Delay days over the weekend, or delay in consultant seeing patient Lack of medical necessity being met
◦ Carve out of procedures for quality of care issues, such as wrong sided surgery or hospital acquired condition
◦ Lack of providing clinical information No information provided Late provision of information
◦ Level of care, such as ICU versus med/surg or intermediate or NICU levels of care◦ One day IP stay changed to observation or outpatient services
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REASONS WE CAUSE DENIALSInternal coordination ◦ Out of network patient: elective or emergent care◦ Late filing for appeals◦ Inadequate processes for notification, verification and authorization◦ Delay in treatment ◦ Mismanagement of observation patients◦ Patient/family delays◦ Registration issues◦ Lack of attention to detail at all entry sites◦ Discharge planning not started timely
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REASONS WE CAUSE DENIALS Financial/billing ◦ Wrong coding◦ Inaccurate billing◦ Late filing◦ Late appeals◦ Wrong payer billed◦ Billing does not match level of care ordered or provided◦ Changing areas of RAC/MAC focus
We don’t close out the account after the patient is discharged with # auth’d days and auth’d level of care
Knowledge ◦ Understanding of contract◦ Understanding of rules and/or regulations State insurance code Federal rules/regulations Out of state Medicaid
Inpatient only errors Contractual issues◦ Late notification, billing, appeals◦ Not providing clinicals Late Incomplete
◦ IP vs observation vs OP◦ Contract planning does not include UM focus
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REASONS WE CAUSE DENIALS Physicians◦ Attending physician does not assume role of captain of the ship with consultants◦ Delays due to physician schedule◦ Delay in consultations◦ Lack of medical necessity Patient does not meet Documentation does not support Physician understanding of medical necessity, status and/or levels of care
◦ Inadequate physician advisor process◦ Lack of physician cooperation with denial process◦ Documentation : Medical necessity, risk of mortality and severity of illness
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REASONS THEY CAUSE DENIALS OR DECREASED REIMBURSEMENT Don’t follow insurance laws, rules and/or regulations
Internal inconsistency Don’t follow contract language Incomplete post acute care network Delay in response to the clinical information we have provided
Post discharge rules/regs◦ Commercial payers◦ Medicare◦ Medicaid
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REASONS THEY CAUSE DENIALSOR DECREASED REIMBURSEMENT
Delays in their case management processes◦ Inadequate case management for specific diseases and $$$ amounts◦ Inadequate on‐site case management◦ Discharge delays with DRG patients
Inadequate networks for timely discharges
Increasing technical denials
Payer medical director available and collaborative
Appeal process ineffective: concurrent and post billing
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CATEGORIZING DENIALS: WHO AND WHERE?
• Front end• Case management: all entry sites• Registration• Physician offices• Physician
• Concurrent • Case management• Ancillary services• Physicians • Nursing care
• Back end • Billing• Coding• Appeal processes
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YOUR DAILY CASE MANAGEMENT STRATEGY
Plan for the day◦ Next step(s) for patient◦ Activity◦ Diet◦ Tests◦ Psycho‐social issues
Plan for the stay◦ DC plan◦ Family involvement◦ Readiness◦ Barriers◦ Payer benefits for next level of care
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KEY HOSPITAL COLLABORATION ROLES
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A HOSPITAL’S MOST VALUABLE ASSETS
Relationship with its physicians
Physicians knowledge and ability to apply it to treat
patients
Physicians ability to articulate care, assessment and treatment through
documentation
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THE ROLE OF THE PHYSICIAN ADVISOR
Serves as a resource for case managers in specific challenging utilization management situations
Increases case manager’s credibility with physician partners
Serves as liaison with medical staff, case management staff, hospital administration, and third party payers
Actively participates in interdisciplinary team conferences
Identified as collaborative and influential member of the medical staff
UTILIZATION MANAGEMENT WITH OUTSOURCED PHYSICIAN ADVISOR
How will physicians be educated?
Do you have an in‐house physician advisor expert?
When do they review? Which payers do they review?
With whom do they communicate?
When do they communicate? Who follows up to assure the physician documents appropriately, should he/she agree with outsourced physician advisor?
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PATIENT & FAMILY Knows their payment source and the benefits for
the payment source Provides accurate and timely information Willing to complete applications for funding Brings in documents for funding applications‐‐
timely Keeps team informed of caregiver change Asks questions related to short term and long term
plans so that expectations are realistic Expresses goals for hospitalization Adheres to patient and/or caregiver
responsibilities agreed upon in the plan of care Follows timely planning for transition
Knowledge of hospital, payer and federal criteria used for medical necessity
Big picture thinker Mover, shaker, and multitasker Well‐respected by clinical team Partners with clinical nurses and
physicians in facilitating interdisciplinary team meetings
Uses evidence based practice to help choose best available healthcare interventions
Incorporates UM and resource management with care coordination and discharge planning roles
RN CASE MANAGER Follows compliance rules and
regulations Savvy negotiating skills with payers,
vendors, providers, and patient/families
Accurately tracks variances/avoidable days
Cost conscious ◦ Clinical resource utilization, cost containment, and revenue enhancement◦ Knows and respects patient benefits
Focuses on plan for stay, as well as plan for the day
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SOCIAL WORK CASE MANAGER Completes a psychosocial assessment to identify issues, which could include payment source issues
Provides psychosocial specialty consultation Provides crisis intervention and advocacy Works with RN case manager for clinical expertise/collaboration
Provides assistance with complex discharge planning Coordinates discussions/processes related to ethical or legal concerns
Provides grief and end of life counseling Serves as knowledge expert for community resources
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BEDSIDE RN CAREGIVER Patient advocate
ClinicalFinancial
Keeps the physician and Interdisciplinary team updated as to changes in patient condition
Makes appropriate referrals within nursing scope Participates in interdisciplinary team meetings and
walking rounds Follows plan of care Follows evidence based best practice nursing
standards Provides ongoing education & support for
patient/family Assists in identifying variances from the plan of care
or from best practice standards
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This presentation is intended solely to provide general information and does not constitute legal advice. Attendance at the presentation or later review of these printed materials
does not create an attorney-client relationship with the presenter(s). You should not take any action based upon any information in this presentation without first consulting legal
counsel familiar with your particular circumstances.