How Improving Case Management Saves MoneyRead Time: 4 minutes
When a patient goes to a hospital, the hospital is expected to make an appropriate decision about whether or not the patient needs to be admitted. This decision is made based on the severity of the person’s symptoms or the presence of a chronic condition, among other factors. When a patient is hospitalized and doesn’t need to be, the result is high costs that were preventable. The key to reducing these improper admissions is better case management.
What is case management?
The case management team at a hospital is responsible for triaging patients to the appropriate locations. Case managers contribute significantly to whether or not a patient is readmitted, a factor that directly impacts reimbursement. These staffs have a goal of improving care coordination and ensuring that patients follow the appropriate care plan after discharge.
Solutions to better case management
Why do case management teams sometimes fail to place patients appropriately? One of the barriers is that hospitals often struggle to have staffing 24/7. In these situations, remote case management teams are a vital resource. Telecase management offers the hospital 24/7 case management coverage, regardless of the full-time staff schedule.
Why is 24/7 coverage necessary?
A large percentage of admissions from the emergency department occur outside of regular business hours. Many hospitals don’t have enough staffing during these windows. When there is not enough coverage, the risk of improper admissions increases. The Centers for Medicare and Medicaid Services (CMS) estimates that $5.7 billion in improper payments is related to inappropriate admissions.
The role of RAC
The Recovery Audit Contractor (RAC) program seeks to identify improper payments, which could be either overpayments or underpayments. When a RAC shows that the hospital was paid for inpatient services when the patients should have been an outpatient case, CMS takes back payment. These audits underscore the necessity of appropriate admissions, as RAC can conclude that the hospital should be receiving little reimbursement.
One element of improving case management is conducting mock audits to prepare for RAC audits. Some hospitals may benefit from an outside team determining the facility’s vulnerabilities and areas for improvement. With this analysis, hospitals can further minimize the risk of denials.
Building a better case management team
Cost is a hot topic in healthcare. Effectively reducing costs will require a multi-pronged, sophisticated approach. One of these strategies is improving case management. For many hospitals, a remote case management team leads to a reduction of improper admissions and significant cost savings.