Improving Reimbursement with Nursing Case Management Status Assignment

Bledsoe, Marlyn K.

Saturday, 29 October 2011

Marlyn K. Bledsoe, MHA, BS, RN
Integrated Care Management, Good Samaritan Hospital, Dayton, OH

Learning Objective 1: The learner will be able to describe the relationship between appropriate status assignment during the admission process and the denial of payment for services rendered.

Learning Objective 2: The learner will be able to identify the value of the role of nurse case managers in status assignment.

Problem: Physicians are expected to assign each patient a status as either observation or inpatient during the hospital admission process. Incorrect status assignment of patients can result in reimbursement problems and denial of payment for services rendered for patients by Medicare, Medicaid and third party insurance companies.

Purpose: The purpose of this study was to evaluate the impact of case managers completing status assignment for patients during the admission process at Good Samaritan Hospital by looking at the denial of payment for services rendered.

Methodology: Denial rates were evaluated for three 15 month time periods: The Pre Intervention (status assignment completed by physicians), Intervention Group A (status assignment completed by case managers) and Intervention Group B (status assignment completed by physicians in collaboration with case managers). Denial data for all DRGs for the identified periods were examined. Ten DRGs were identified as possessing greater than two percent denial rate. All DRGs possessing a greater than two percent denial rate related to status assignment were further explored to identify the rationale for denial of payment and to identify outliers.

Findings/Outcomes: The greatest denial rates for payment occurred during the Pre Intervention Period ,when physicians completed status assignment for patients independently. There was a significant reduction in denial of payment for most DRGs during Intervention A Period when case managers were assigning status independently. The most significant reduction in denial for payment occurred during Intervention Period B when case managers were collaborating with physicians regarding appropriate status assignment.

Implications for Practice: Evaluation of denial data provides an opportunity to target education to physicians regarding status assignment criteria thus reducing denial of payment to the hospital. Evaluation of denial data will provide guidance in consideration of placing status assignment on diagnosis specific order sets to reduce variations in provider ordering practice.

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