Care management reviews boost revenue integrity $60K in under 60 days

Client Profile:

A west coast hospital system with five acute care facilities and over 50,000 bed placements per year.

Practice Leader:

Karen Haesloop, RN, FNP, MSN, Director of Care Management

Challenge:

The hospital system had been unable to adequately staff emergency departments with utilization review care managers seven days per week, with a minimum of 12 hours per day. As a result, patient status determinations on an average of 120 admissions per day were not substantiated until more than 24 hours after admission.

The system experienced an increase in inpatient admission denials from commercial payers due to untimely medical necessity utilization reviews, which were lacking the proper clinical documentation to verify the appropriate inpatient admission.

Solution:

McBee deployed an experienced team of remote utilization review nurse care managers to monitor the emergency bed boards 12 hours per day during the afternoon and evening hours, seven days per week to fill shortages. The care managers quickly identified patients assigned to a hospital bed and reviewed the medical necessity of their admission status. These reviews yielded a solid, real-time admission status decision using a nationally recognized screening criteria and supported by documentation.

Results:

Our concurrent, real-time reviews justified 86% of all initial inpatient status orders as meeting inpatient medical necessity. Completing these reviews early in the patient stay allowed the provider to meet timely filing and provide proper clinical documentation to support the inpatient status decision. This resulted in a greater than $60K revenue integrity improvement in under 60 days. In addition, the number of patients with an inpatient status order that only met observation status was significantly minimized to 1%. This has protected the hospital from initial patient status downgrades (Code 44) that are often the focus of Medicare audits.

McBee ensured the hospital maintained compliant, appropriate documentation for status orders upon admission and defensible documentation to thwart an admission denial. The integrity of the revenue generated from the appropriate status was determined and maintained early in the patient stay, most often before the first midnight was crossed.