1,000 bed urban hospital in the Northeast
This hospital was consistently denied an average of $1 million per month from third-party payers, mostly for one-day inpatient stays through the ED for which documentation reflected observation level of care. Because the ED was short-staffed, the department was also routinely denied for claims submitted without clinical reviews and authorizations for each of the 60 to 70 admissions per day to the ED.
Working with the chief ED physician, McBee designed a process for our case managers, who are experts in medical necessity criteria, to remotely review all pending ED admissions and confirm appropriate status (admission vs. observation, etc.) on the first-level. McBee case managers notified physicians when documentation did not meet inpatient admission criteria, and the cases were flagged for follow up as a potential denial. The first-level review methods were designed to guide admitting physicians in making informed decisions about whether cases meet criteria.
Because our case managers were remote, they were able to open dialogue with physicians on documentation without disrupting the physicians’ flow of patient care.
Our case managers also assisted the hospital nurses with providing timely clinical reviews and authorizations to prevent automatic denials for no clinical information.
During the first week of first-level concurrent reviews, the ED department denial rate dropped to half its previous rate—from 173 denials per week to 87. Denied dollars dropped by 43%, and the department has sustained a lower denial rate since the start of service.
The hospital’s department leadership and physicians embraced the review process culturally. The services led to continued dialogue about appropriate admission status, proper use of medical necessity criteria, and the importance of thorough documentation throughout the facility.
“The difficulty is in understanding what the rules are for getting paid and translating the rules into concepts that physicians can appreciate. That’s what this service does successfully.”
— Chief medical information officer and ED physician