PP211 – Teamwork makes the dream work: Collaborations in Case Closures
The Institute for Health Improvement created the Quadruple Aim. One Aim is improving patient cost per capita. To achieve this Aim, Case Management (CM) departments must ensure that financial measures are met including an effective Utilization Review (UR) program to help reduce denials, closes cases and increase payments by health plans.
Review of the delivery model at MD Anderson Cancer Center by the CM department revealed that CMs were not adequately meeting their UR objectives because of competing demands as dual Discharge Planners (DCP) and UR CMs.
To met the improving patient cost per capita Aim, an effective UR program is needed that is separate from DCP. Therefore, a pilot was created to detached UR and DCP by CMs and place an increase focus on case closures (CC) of hospital records.
CC within 4days of discharge are essential for controlling potential denials and ensuring all care days are authorized. After 4days, the billing department submits the final bill to the payor and the hospital record is at jeopardy of having a denial if adequate documentation and closure has not transpired.
This program will show a successful transition in case management model with proven results in the area of CC. Pre-pilot approximately 54% of cases were closed within 4days. Since the pilot, CC have increased to an average of 90%.
If cases are managed by dedicated UR nurses, they can adequately submit clinical to payors and identify at risk areas that can be addressed and corrected before submitted to the health plan. After discharge, a plan to have CM Assistants review cases immediately for closure will help ensure proper documentation and clinical is obtained. Initial stages of the pilot have shown a successful improvement in quality and efficiency by the CM Department. The benefits of achieving at least 90% of case closures before the 4th day of discharge will ensure that days have been approved properly and care has been authorized and mitigate denials by health plans.