Medical necessity denials
We are enduring our first RAC audit. So far, they have denied 2/3 of the records for Inpt vs.Observation. At this point CDI is not part of the review process or appeal process. Presently one UM nurse and our MD advisor review these records for appeal. Thus far, they have appealed 2 of the 119 denials. We have no official RAC team or RAC coordinator. CDI is being considered in the ED. Another approach they are seriously leaning toward is investing in a company called EHR or Executive Health Resources. It is a company that employs MDs to review records concurrently to determine medical necessity and also write appeals. It looks pretty slick. Is anyone familiar with this company or using this company? It is pricey. I am wondering what other systems do to thwart denials and ensure proper patient status. My hospital has a history of using rather unorthodox means of maintaining compliance. I don't want to see them go down another needlessly expensive path. Thanks for any input!
Comments
I just heard a summary of the financial impact yesterday, and it sounded good. Senior management was very pleased.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Dorie Douthit, RHIT,CCS
ddouthit@stmarysathens.org
Thanks,
Kathy
Kathy Shumpert, RN, CCDS
Clinical Documentation Improvement Specialist
Community Howard Regional Health
3500 S Lafountain
PO Box 9011
Kokomo, IN 46904
Office 765-864-8754
Cell phone 765-431-0123
Fax 765-453-8447
When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
The nicely written note they send citing the clinical indicators they are using to validate the admission smack of some term papers in college I turned in at the last minute...
We almost sent them walking this year but decided to keep them for a while longer.
N. Brunson, RHIA,CDIP,CCDS
Karen
Karen McKaig, BSN, RN, CCM, CPUR, CCDS
Case Manager
Clinical Documentation Specialist
Baxter Regional Medical Center
Mountain Home, AR 72653
870-508-1499
kmckaig@baxterregional.org
-Jane
Diane Draize RN, CPUR,CCDS
Clinical Documentation Specialist
Ministry Door County Medical Center
diane.draize@ministryhealth.org
920-743-5566 ex 3143
We earn trust by working together as One Ministry to keep PATIENTS FIRST in everything we do
Sharon
Sharon Cooper, RN-BC, CCS, CCDS, CDIP
AHIMA-Approved ICD-10-CM/PCS Trainer
Owensboro Medical Health System
Manager Clinical Documentation & Appeals
P.O. Box 20007
Owensboro, KY 42304-0007
(270) 688-1277 Office
(270) 316-9088 Cell
(270) 688-2737 Fax
sharon.cooper@omhs.org
TEAM = Together Everyone Accomplishes More!
One thing I am absolutely struck by, is the essentially ZERO rate of appeals. WAY off from the national trend. Appeals are often successful....either there are much bigger issues on determining status (in vs out), or the decision to appeal must be bumped up by orders of magnitude. As I recall there might have been something in the CDI Strategies e-newsletter that shared information from AHA about appeal rates and successes. Seems appeal should be at least 33% if I remember.
On EHR...many engage them, I'd describe as the gold standard for support. My impression is that our hospital is satisfied with their services though I am not involved with UR (CDI only).
From a CDI perspective, working in the ED & ensuring documentation to support inpt vs outpt would seem to me to be included in the CDI scope, or alternatively simply working to ensure full & complete descriptive detailed documentation is present to give UR the information to work with.
Do watch staffing / resources and clear expectations for prioritization.
Make sure you have received clear direction about what to do & that your partners (UR, etc.) are meshed in together so everyone is effective.
Don
management to assist in the ED we have been talking about moving our CDI
process into the ED to work with both documentation issues and
observation/inpatient status issues. We are early in the tihinking process
on this. Any ideas, experience in the area of CDI in the Emergency room
would be welcome information.
While staffing is an issue, my thought is that- at this point in our institution anyway-, CDI is the frosting on the cupcake. Frosting makes the cupcake complete and perfect. If the oven is broken (i.e the ED documentation) we aren't getting any cupcakes to frost. We currently have backend solutions performed by UM such as simply not billing for Observation services, re-reviewing 2 day Inpatient stays post discharge to ensure they met medical necessity and if the UM nurse does not think it was met; these record are billed only ancillary charges and not for inpatient admission. Can you see the conundrum we are in? In the latter case, we are frosting cupcakes that, ultimately, get thrown out!
As far as clear direction, I am a renegade on this one and forging my own path. The c suite does not understand the process. So UM has implemented these practices to avoid errors in status. I think having CDI in the ED would be a frontend solution. I am sure this is difficult to imagine, but UM and CDI are not on the same page currently.
I always say, UM sees what is written. CDI sees what could be written. We need to work together. I am pushing for this to change. We shall see what happens...
Thanks again, Don!
Jane