Revenue Integrity Standards and Accreditation in Healthcare. Case Management Accreditation Standards

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1 Revenue Integrity Standards and Accreditation in Healthcare Case Management Accreditation Standards CASE MANAGEMENT Summary Measuring performance helps hospitals assess revenue cycle efficiency and effectiveness. Monitoring the Case Management standards will ensure compliance with value-based purchasing and quality measure requirements and will encourage patient care coordination resulting in improved patient satisfaction. Hospital Case Managers are valuable for their understanding of healthcare delivery and their ability to combine quality, efficiency and resource management in delivery of patient care. Well-organized and executed utilization management activities in hospitals translate to smoother operations for health plans and an uninterrupted revenue cycle for hospitals. The role of the case manager has become increasingly important with increased pressures to control cost of care, and the trend to withhold reimbursement for inappropriate admissions and extensions of inpatient stays, beyond that which is medically necessary. Nursing Case Managers are often conflicted between providing the best patient care and helping to meet the financial needs of the hospital. Hospital policy should be clear to assist Case Managers in making decisions regarding utilization of services. Management should be supportive and help liaison with the physicians. Successful Case Management departments have access to integrated tools containing access to EMR patient information, both clinical and financial, system tracking of patient length of stay (LOS) information and processes in place for physician reviews of discharge delays and stays that are not meeting medical necessity. Monitoring standards will help hospitals identify areas of improvement needed and will assist in establishing measurements for progress.

2 CM-01 Patient status is correct on Admission. CM Patients should be in the correct status of Inpatient or Observation at the time of admission. CM Any patient with a status change due to an incorrect status on admission, should have accurate and complete documentation in the chart including; reason for status change, order for status change, condition code 44 if appropriate. CM Best Practice Standard is 95% of patients holding a bed other than ER and Day Surgery have a correct status order at the time of admission. Rationale for CM-01 Determining the patient status at the time of admission ensures billing compliance and communication with other providers. Patient status is the decision of the physician, in coordination with the Utilization Review committee, and effective management is essential in reducing the risk of inappropriate admissions. Demonstrating compliance shows a hospital s commitment to quality care. Tracking of patients should include patient account numbers for survey identification and review. This standard should be tracked concurrently and totaled at least monthly for review. Equation: N: The total number of patients in correct status at time of admission D: The total number of inpatient and observation patients holding a bed

3 CM-02 Inpatient discharge planning begins within 24 hours of admission. CM The hospital should have documentation that shows discharge planning was begun within 24 hours of admission. The documentation must be in the patient record. CM Documentation of discharge planning can include; Initial Case Management Assessment, Nursing notes discussing discharge status plans/information, etc. Documentation with a check mark in a nursing admission assessment will not suffice unless there are additional notes to support the discharge planning. CM Best Practice Standard is 100% of patients admitted to Inpatient status have discharge planning documented as beginning within 24 hours of admission. Rationale for CM-02 Beginning discharge planning at the time of admission is a part of the Medicare Conditions of Participation for hospitals. Complying with these conditions decreases the potential for readmission and ensures patient care and safety when discharged from the hospital. Improvements in hospital discharge planning can dramatically improve patient outcomes as they transition to the next level of care. This standard can be tracked by utilizing a sampling of records, chosen at random, monthly, with documentation of findings maintained. Equation: N: Total number of inpatients audited with documentation of discharge planning at the time of admission D: Total number of inpatients audited

4 CM-03 Inpatient certification of admission is completed on Medicare patients CM The hospital must show documentation of the physician s decision on the anticipated length of stay (LOS) in the record. CM The patient admission status must match the documented intent of the physician certification for a medically necessary stay as required by CMS. CM Best Practice Standard is 100% of patients admitted will have a complete certification of admission and the patient status will reflect the physician intent. Rationale for CM-03 Complying with the 2-midnight rule and the guidelines for physician certifications are mandated by CMS. Hospitals must be able to show documentation of physician intent and medical necessity of admissions. The patient status should match the physician intent to ensure compliance. More information on the CMS guidelines can be found at the link below. This standard can be tracked by utilizing a sampling of records, chosen at random, monthly, with documentation of findings maintained. Equation: N: Total number of Medicare patients audited with inpatient certification D: Total number of Medicare inpatients audited

5 CM-04 Percent of inpatient t dollars denied for clinically inappropriate. CM The hospital must track inpatient denials resulting from an insurance company determining the admission is clinically inappropriate or medically unnecessary. CM Best Practice Standard is no greater than 0.1% of net hospital revenue. Rationale for CM-04 Inpatient denials are potentially a large revenue loss for hospitals. Tracking denials, for accounts deemed clinically inappropriate, will enable hospitals to evaluate processes and provide education to decrease loss. Monitoring these denials by insurance company, physician, diagnosis and type of patient will enable hospitals to accurately determine where the highest risk for loss is originating. When tallying data for these accounts, accounts that remain in appeals should be tallied. If an appeal has been successful the account should not be included in the total of denials. Equation: N: Total dollars of inpatient revenue denied as clinically inappropriate D: Total dollars of inpatient revenue