Document Detail

Improving reimbursement with nursing case manager status assignment.
MedLine Citation:
PMID:  23389707     Owner:  NLM     Status:  In-Data-Review    
PROBLEM: : Historically, physicians completed status assignment during the admission process. Incorrect status assignment of patients can result in reimbursement problems and denial of payment by Medicare, Medicaid, and private insurance companies.
PURPOSE: : The purpose of this study was to evaluate the impact of case manager's role with status assignment during the admission process by looking at the denial of payment for services rendered.
METHODOLOGY: : Denial rates were evaluated for two 15-month time periods: preintervention group (status assignment completed by physicians) and intervention group (status assignment recommended by case managers with physician signature). Denial data for all diagnosis-related groups possessing a more than 2% denial rate related to status assignment were further examined to identify the rationale for denial of payment. FINDINGS/OUTCOMES:: The greatest denial rates for payment occurred during the Preintervention Period, when physicians assigned status for patients independently. There was a significant reduction in denial of payment for most diagnosis-related groups during the Intervention time period when case managers were recommending status assignment.
IMPLICATIONS FOR PRACTICE: : Evaluation of denial data provides an opportunity to target creative performance improvement solutions to reduce denial of payment related to incorrect status assignment.
Marlyn K Bledsoe; Michele L Marshall
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Professional case management     Volume:  18     ISSN:  1932-8095     ISO Abbreviation:  Prof Case Manag     Publication Date:  2013 Mar 
Date Detail:
Created Date:  2013-02-07     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  101291585     Medline TA:  Prof Case Manag     Country:  United States    
Other Details:
Languages:  eng     Pagination:  79-83     Citation Subset:  N    
Marlyn K. Bledsoe MHA, RN, is a clinical analyst at Center for Status Integrity for Premier Health Partners. She is responsible for collaboration with physicians for correct status assignment and utilization review. Michele L. Marshall, MS, RN, CNS, NE-BC, CPHQ, is a senior health services researcher at Good Samaritan Hospital, part of the Premiere Healthcare Partners Network in Dayton, Ohio. She is responsible for facilitating interdisciplinary research and evidence-based practice initiatives.
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