case management department - advance · impacts case management ... tool that will determine the...
TRANSCRIPT
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CHANGING YOUR CASE MANAGEMENT
MODEL OF CARE
Jan Lear, RN, CMC
Director of Case Management
MedStar Franklin Square Medical Center
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Program Objectives
• To be able to describe the compliance and regulatory
knowledge of Medicare and Medicaid Program that
impacts case management
• To be able to explain the difference between the Dyad
and Triad models for case management
• To be prepared to use data and develop a workflow
tool that will determine the skill mix and outcomes
needed to meet future needs of your case
management department
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Case Management
Reimbursement and Regulatory Challenges
RAC/MAC Audits Hospital
Condition of
Participation
Readmissions
Observation Important
Message InterQual
Condition 44 PEPPER Report
Face to Face
Form
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Reimbursement and Regulatory Challenges
RAC/MAC
Changing the Reimbursement of Your Hospital
Impact on Your Appeal Department
Each Denial Has The Capacity to be Handled Five Times
Pre-Payment Audits - Hips and Knees
PEPPER Report
Hospital Condition
of
Participation
Discharge Planning
Utilization Review
UR Committee
Code 44
Admission Status, Level of Care
LOS - Outliers
Readmissions
Multi-Disciplinary Team
Transitional Care Nurses - New Relationships with
Sub Acute Facilities, Home Health Agencies, PCP
ED Presence return to Sub Acute or HHA
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Reimbursement and Regulatory Challenges
Inpatient
vs
Observation
Correct admission status
Calculating the hours
Complete physician orders
Condition Code 44
Observation Letters
InterQual and Milliman Criteria
Other
Potentially Preventable Complications
Important Message
Face to Face Form
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Hospitals put 7-figure price tag on
readmission penalties
CMS announces official start date for
Recovery Auditor prepayment reviews
Observation stays may hurt some patients
Boston Teaching Hospital fined $ 1.5M for
ePHI data breach
Case Management Department
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Social Workers
Utilization Review
Denials/Appeals
Core Measures
Deliver Highest Quality Care at Lowest Costs
Case Managers
Clinical Documentation
Case Management Department
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Dyad Model of Care
Care Coordination
Discharge
Planning
Utilization Review
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Case Managers
Utilization Review
Care of Medically Complex Patients
Resource Management
Discharge Planning- Medical Complex Patients
Core Measures – Outcomes
Interdisciplinary Rounds
Medicare Discharge Appeal Letters
Medical Necessity of Admissions – 100% of admissions
Clinical Review
Appropriate Admission Status and Level of Care
Orders are Written Correctly
Retrospective Appeals
Condition 44
Readmissions
Prevention of Denials/Appeals
Social Workers Performs Psycho-Social Assessments
Guardianship, Ethical or Legal Concerns
Financial Assessments – Self Pay- Uncomp, Homeless
Substance, Elder, Child, Domestic Abuse
Adoption, Homeless, Transportation,
Advance Directives, End of Life, Crisis Intervention
CM/SW Shared
Responsibilities
Discharge Planning
Important Message
Face to Face Form for Home Health
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Triad Model of Care
Care Coordination
Discharge Planning
Utilization Review
Utilization Review Nurse
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Case Managers
Coordination of Care
Resource Management
Discharge Planning- Medical Complex Patients
Core Measures – Outcomes Management
Interdisciplinary Rounds
Medicare Discharge Appeal Letters
Social Workers
Performs Psycho-Social Assessments
Guardianship, Ethical or Legal Concerns
Financial Assessments – Self Pay- Uncomp,
Homeless
Substance, Elder, Child, Domestic Abuse
Adoption, Homeless, Transportation,
Advance Directives, End of Life, Crisis Intervention
Utilization Review
Medical Necessity of Admissions - 100% of
Admissions
Clinical Reviews
Appropriate Admission Status and Level of
Care,
Orders are Written Correctly
3808’s
Denial Management
Appeals
Payor Specialist
Concurrent Management of Denials
RAC/MAC
Resource Department
Transportation
Interpreter Services
Supplies
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Future Decisions
• What Data do I Need?
• What Skill Mix Do I Need?
• What Outcomes Do I Want?
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Data Elements
Total Admissions Inpatient Observation
ED Visits
Case Mix Index Denials
Payor Mix
Discharge Planning UR Functions
Social Interventions
LOS
Initial Assessment
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Care Coordination
FY 2012 Total % Inpatient Versus Observation
FY 2011 Total % Inpatient Versus Observation
Admissions Inpatient 16,569 79% 16,031 83%
Observation 4,410 21% 3,363 17%
ED Visits 66,375 68,327
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Care Coordination
Current YTD Actual
Percentage Of Total Admissions
Prior YTD Actual
Percentage Of Total Admissions
LOS 4.11 4.07
Less then 1 day 847 4% 808 4%
One Day 5,273 25% 5,042 26%
Two Days 5,384 26% 4,919 25%
Three Days 3,560 17% 3,129 16%
Over three days
5,813 28% 5,411 29%
Total Admissions
20,877 19,309
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Care Coordination
Current YTD Actual
% of Total Admissions
Prior YTD Actual
% of Total Admissions
Patient Assessments
7,950
38%
7,792
40%
D/C Planning Notes
23,024 22,619
Problem Notes 57,832 44,122
Total Admissions
20,877 19,309
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Psycho Social Interventions
Current YTD Actual Prior YTD Actual
Total Psycho Social Interventions
4,586
5,776
Assessments 1,763 1,696
Family Meetings 129 176
Advance Directives 87 184
Hospice Placement 240 368
Insurance Issues 123 128
Substance Abuse 201 208
Abuse/Neglect 67 64
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Current YTD Actual
Prior YTD Actual
Top 5 Payors Medicare 7,783 7,045
Med Star Family
1,338 1,305
Blue Cross 1,819 1,377
Self Pay 781 706
Medicaid Pending
339 183
Utilization Review
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Utilization Review
Current YTD Actual
Prior YTD Actual
Correct Status, Level of Care
20,979 19,394
Observation Charges
4,410 3,363
MCR Reviews For Correct Status (Every 3 days)
7,783 7,045
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Commercial - Denials and Appeals
Current Total # Claims
Prior Total # Claims
Current YTD Actual
Prior YTD Actual
Current Total Dollars
Prior Total Dollars
Denied Days 629 669 1,229 1,374 $1,702,054 $1,522,603
Overturned Days
110 184 278 292 $395,154 $351,283
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RAC - Denials and Appeals
June 2011 to Current
Total # Claims
Open Closed Current Total Dollars at Risk
Total Dollars Overturned
Percentage Overturned
Round One 128 106 22 $215,713 $44,460 21%
Round Two 128 31 97 $189,002 $67,654 36%
Round Three 89 60 29 $129,375 $71,829 56%
Round Four 128 128 0 $234,756 0
Total $768,846 $183,943 24%
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MAC - Denials and Appeals
Current
Total # Claims
Appealed Not Appealed Overturned Current Total Dollars at Risk
Total Dollars Overturned
91 65 26 18 $379,817 $25,408
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Readmissions
Feb Current All Admissions
Current FY Readmissions
Percentage
Prior All Admissions
Prior FY Readmissions
Percentage
All 16,345 1,741 11% 16,621 2,253 13.56%
CHF 527 113 21% 496 124 25%
COPD 546 98 18% 572 109 19%
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FY 11 July Aug Sept Oct Nov Dec Jan YTD
11.2% 10.4% 11.6% 10.5% 9.8% 10.6% 10.2% 9.9% 10.4%
MFSMC Readmission Rates
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Work Flow Tool Chemical Dependency Assessment Advance Directive
Family Meeting End of Life
Guardianship Locating Family Members
Psych Placement Medication Assistance
Homeless Requesting Intervention Cultural or Language Issues
Frequent Admissions HIV Resources
Domestic Violence Insurance Issues
Death No Prenatal Care
Foster Care Follow -up
Social Worker
Work Flow Tool
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Completing UR’s Assessment
Specialized DME – BiPAP/CPAP Acute Rehab
Medications - Antibiotics Ventilator Placement
Medications – Coagulation Patient Complaint
TPN Home Care
Insurance Issues- Medical Necessity KePro – Level of Care
Family Meetings Transfer to Another Hospital
Radiation Therapy Specialized DME – Specialty Beds
Specialized DME – Wound VAC Outpt Dialysis
Nurse Case Manager
Work Flow Tool
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Work Flow Tool
Level One Any intervention that lasts 15 minutes or less
Level Two Any intervention that lasts 16-30 minutes
Level Three Any intervention that lasts 31-60 minutes
Level Four Any intervention that lasts over 60 minutes
Requires a narrative note
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Skill Mix
Type of Units Patient Types
Types of Services Provided Volumes
Inpatient /Outpatient Outcomes/Goals
Case Manager Appeal Nurses
Social Worker Utilization Review Nurses
Documentation Specialist Transitional Care Nurses
