Don't 'manage' denials - Prevent them.
The only way to prevent denials is knowing what actions are causing them. A root cause analysis begins with 'first pass' denial information transmitted by the payer to the hospital via the 835 report. [...]
Hospital Case Management Advisor - 2016 Article Archive
2016 Articles
by Phoenix Medical Management, Inc.
The articles on this page were published by us throughout 2016. As with all our written work, we welcome your thoughts or critique. Feel free to send an email to editor@phoenixmed.net.
A New MOON Rises
CMS introduced a free text field in the written MOON form requiring that someone specify the reason(s) a patient is being placed in observation. The chief compliance officer should consult with leadership to decide which staff members are appropriate to complete that section. But you can make it easier by using check-boxes. [...]
Determining need for inpatient care
Patients may be placed in observation when the patient’s condition is rapidly changing, further diagnostic testing is required and it is not clear if inpatient care is needed. After several hours, but no more than 1 midnight, a reassessment is made to determine if the patient requires inpatient admission, or may be discharged and receive followup in the outpatient setting. [...]
Physician-Level Practice Variation
That physician factors can explain both the overuse of unnecessary services and the under-use of clinically indicated services across clinical entities suggests physician-level variation is not only pervasive, but substantially impacts the cost, quality, and value of care delivered across a wide spectrum of clinical services. [...]
5 Easy Pieces
The goal of care coordination is shown in the middle of the diagram.The colored circles represent some possible participants,settings,& information needed for effective CC. The blue ring connecting the colored circles is CC—namely, anything that bridges gaps & improve coordination. [...]
What Can the Dallas Cowboys Teach Us?
Huddle time must become a part of everyone's daily routine. And that will happen if participants perceive it to be of value. So, each member must come with knowledge about their patient and progression-of-care recommendations. Experiment with different participants and how information can be shared with non-participants. Establish a time-limit and stick to it. [...]
Care Management in a Value Based Marketplace - Part 2
Researchers have long argued that the survival of an organiation is dependent on its continuous interaction with its environment. The hospital environment includes the current and changing marketplace, governing regulations, and the available resources. This same thinking applies to care management which must innovate to stay current. [...]
Care Management in a Value Based Marketplace
The transformation to value-based health care is well under way. Some organizations are still at the stage of pilots and initiatives in individual practice areas. Other organizations, such as the Cleveland Clinic have undertaken large-scale changes involving multiple components of the value agenda. Making this transformation is not a single step but an overarching strategy. [...]
Medicare's Nursing Home Compare
New quality measures for skilled nursing facilities will be added to Nursing Home Compare beginning in April. Data for six new quality measures — some based on Medicare claims, others on MDS data will be useful to consumers and to care managers as they provide important information about quality of care outcomes that wasn't covered previously on Nursing Home Compare. [...]
Transition Clinics
A Transitional Clinic is one of the innovative approaches to value based care and a way of keeping patients connected to the highest quality care as they make the transition from the hospital to home or a post-acute care facility. [...]
Football Team at the Obamacare Buffet
How an all-you-can-eat menu is making health insurance plans more costly and stingy. Insurers re switching out the lobster for fried chicken, and charging more for it. This article appeared in the NY Times, Sunday, Sept 25, 2016 [...]
Predictive Analytics is transforming health care
Hospitals have a powerful new tool — predictive analytics — that can help them use their untapped troves of data to improve patient care, become more efficient and lower costs. The shift from FFS to value-based reimbursement is driving the need for sophisticated analytics systems that can quantitate and track quality measures. [...]
Transmittal 541 Comes Alive
If admitting physician's documentation, including history and physical and progress notes, doesn’t support medical necessity of an inpatient surgical procedure, the surgeon’s Part B claim for performing the procedure can be denied. Transmittal 541 continues to allow the denial of the physician’s claim without requesting records from the physician, meaning the physician’s claim may be denied based [...]
Advocacy and the Care Manager
Patient advocacy is not new for case managers. It is a moral obligation traced back to NYC social workers helping newly arriving immigrants. But hospital case managers do not always act at an optimal level of advocacy and often accept only what they can do. Many consider advocacy contextually complex, and in some facilities, a controversial and risky component of case management practice. [...]
The Future and the Case Management Program
The threat to American hospitals began with the introduction of the prospective payment system, continued through the 1999 publication of the IOM report, To Err is Human and continues as execs struggle to prepare for the future. In response to these challenges and the additional pressures of increasing costs and new payment models,a progressive model of case management is essential. [...]
Bend the Cost Curve and Eliminate Waste
Excess costs across the healthcare system, combined with lower than acceptable value affects all of us. Expenditures per capita on federal, state, and local levels and as a percentage of gross domestic product are rising in spite of efforts to curtail healthcare costs. And although quality outcomes have improved, so has the cost of care. [...]
Three Easy Pieces
There are many changes that need to be made to transform a traditional, task oriented case management program into a model which more closely reflects the changes in the marketplace. These three strategies - reorientation of the care manager's role, physician education, and a PARC program will help the program Director close the gap between fee for volume and fee for service. [...]
Accountable Care Units
Accountable Care Units (ACU) generally have four key features: unit-based Hospitalist teams; structured interdisciplinary bedside rounds; unit-level performance reports and rewards for achieving pre-determined outcomes; and unit co-management by the nurse manager, the care coordinator, and medical director. [...]
Adapt and Thrive
Responsible case management adaptation encompasses the strategies, actions and partnerships through which programs adapt to marketplace impacts because it provides some improved function and creates shared benefits for the stakeholders they serve. [...]
Analytic Intelligence
Bundled payments, global payments, and shared savings plans. All new as part of healthcare's reform initiatives driven by the ACA. To stay financially viable, hospital leaders must understand their total costs in order to manage them. [...]
The Hospital Care Manager
Care coordination, the key component of a hospital's contemporary comprehensive case management program, can improve the clinical and economic outcomes for high-risk patients and positions the care manager's integration into transitional care and population health. [...]
True North
Every case management leader must discover their True North and stay on course of their beliefs and values throughout their career, so they can realize the fulfillment of leading others with a common purpose. [...]
Avoid Overtreatment
Swedish Medical Center in Colorado embraced Choosing Wisely recommendations against too-frequent ordering of lab tests. They undertook a review of ordering patterns and found five or six out of a staff of 60 physicians were responsible for 50 percent of daily labs. Hospital leaders created a simple e-mail based intervention that included data on physician ordering patterns, coupled with educationa [...]
Access Management
Halifax Hospital Medical Center and Halifax Staffing Inc. (Halifax), a hospital system based in the Daytona Beach, Fla., area, paid $85 million to resolve allegations that they violated the False Claims Act by submitting claims to the Medicare program that violated the Physician Self-Referral Law, commonly known as the Stark Law. [...]
PARC + PDC
There are pros and cons of having hospitalists briefly leave the hospital units to see patients in the post discharge clinic. On the downside, there may be a temporary gap of continuity with the patient's primary care physician. On the upside, patients benefit in terms of meeting with someone who actually knows the care they received in the hospital. [...]
Culture Eats Strategy for Breakfast
The reasons for variation among hospitals in mortality rates for patients with acute myocardial infarction are not well-understood. A 2011 qualitative study of interviews with staff of high- and low-performing hospitals found that such characteristics as organizational values of excellence, innovative approaches to problem solving, and good coordination among clinicians distinguished hospitals wit [...]
Outcomes Count for Patients and Care Managers
The changes taking place in hospital case management programs are the result of forward thinking leaders who recognize that hospital case management programs must keep pace with the changing marketplace. Progression of care must be safe and efficient and often the care manager is the only consistent resource available to the patient. [...]
The Observation Unit
The efficiency achieved by using observation for up to 24 hours rather than a typical short stay admission reduces the patient's exposure to the well documented dangers of inpatient hospitalization. [...]
Organized care and information sharing
From the AHRQ (2015),care coordination is the"deliberate organization of pt care activities & info sharing among all the participants concerned with a patient’s care to achieve safer and more effective care." The CCMC states that a care manager facilitates care resources throughout the continuum "while ensuring that the care provided is safe,effective,client-centered, timely,efficient,& equitable. [...]
Physician Advisors
A Physician Advisor(PA)brings a unique skill set to the clinical environment to help the medical staff navigate through the rules governing the business of healthcare. Whether working with the utilization review specialists, the care managers, or the clinical documentation improvement experts, the role of the PA is an essential ingredient to navigate the turbulent waters of a value based system. [...]
Group Medical Visits Are Catching On
In a typical doctor's visit, you wait around for a while, get your vitals checked, and spend a few minutes alone in a room with a physician. It's private and short. Some doctors, frustrated by a relentless schedule of 15-minute, one-on-one visits, are experimenting with appointments that are neither. [...]
PhoenixMed at ACMA 2016
Probably the most exciting part of a national conference is the opportunity to network with colleagues, friends, and clients from across the Country. The 2016 ACMA Conference held in Tampa Florida earlier this week was no exception. [...]
Hirsch's Law
There is no national observation rate benchmark. CMS does not publish such data and any organization claiming to have such a rate is just creating it from its own database, with no guarantees that they are following the rules or even calculating their observation rate the same for all facilities in the “benchmark group.” [...]
The Business Case For Hospital Case Management
Physician relationships, a growing number of hospital-based physicians, protective gatekeeping, promoting evidence based practice and overcoming delivery-of-care barriers are just some of the reasons to reinvent a hospital’s case management program, say contributors Stefani Daniels and Richard Reece, M.D. [...]
The Myth of Length of Stay
When several readers brought to our attention that this article is no longer available on HealthLeader's Media web site, we decided to post it on our blog. It's as relevant today as it was when origianlly published in 2008. [...]
Beware of HIPAA Zealots
Fear of punishment and lack of training can lead to case management professionals to misinterpret the law's requirements. [...]
Is It Time To Dump The Pagers?
The advent of cellular phones led to a rapid decline in beeper use, but they are still in widespread use. If doctors were among the first adopters of paging technology, they will almost certainly be the last to abandon it. [...]
Do You Have A PARC Ranger on Your Team?
Approximately 53% of hospital discharges are considered 'routine' and typically include disch to home, disch to home w/HH or return to an ECF or SNF. Post acute plans for these patients are generally developed by the nursing staff with the logistical assistance of a PARC. Using an HL7 interface, a web based portal to an automated post acute application can speed up the discharge process significan [...]
The Hospital UR Plan
A solid UR plan should provide clarity of purpose and application of processes as they relate to managing regular Medicare and Medicaid patients through each acute episode of care, from admission to discharge. [...]
2016 Case Management Education Programs Announced
Start the New Year off on a best practice foot and bring in the PhoenixMed experts to help case managers and UR specialists understand the new marketplace, how to engage their medical and clinical colleagues in efficiently managing progression of care, and to translate the eithical obligation of advocacy into practical, real-time resource management monitoring. [...]