Editor’s note: This article is the second in a two-part series on patient status.

Developing clear patient status indicators helps improve quality of care. Creating a case management protocol (CMP) based on these clinically approved indicators helps clinical and admissions staff members determine the appropriate patient status, which in turn helps reduce admissions claims denials.

“I can’t imagine that hospitals wouldn’t want to get their auditing strengthened and use something like a case management protocol to determine the correct patient status,” says Suzanne K. Powell, BSN, RN, MBA, CPHQ, CCM, of Florida’s Quality Improvement Organization (FQIO). A recent study, coauthored by Powell, demonstrated reductions in unnecessary Medicare hospital admissions for chest pain through the use of CMPs in participating Arizona and Florida hospitals.

The FQIO study supports the use of CMPs to appropriately identify, and subsequently bill for, patient status. As a result of applying the chest pain guidance tool, participating hospitals in Florida reduced projected admissions denials by 67% for patients assigned a DRG of 143, chest pain. Participating Arizona hospitals reduced the number of one-day inpatient admissions for chest pain by 90%.

FQIO’s CMP process relies on two-way communication between case managers and physicians. It recommends that facilities have utilization review (UR) management, case management, and other key members of the medical staff approve the protocol prior to implementation.

Participating hospitals found the FQIO’s CMP and the chest pain admission guidance tool fairly flexible. Some adapted the tool and CMP to their specific needs. For example, a few hospitals did not allow for a hold status—a time frame of two to six hours that allows time for case management/UR staff members to assess the admitted patient.

However, these hospitals defined a patient’s status when presenting as inpatient or observation within the CMP and adopted a default-to-observation status if a patient’s status was not defined within 12 hours.

One Arizona hospital began a chest pain unit, and another, a clinical decision unit within their emergency departments to determine patient status.

How does a CMP work?

Once the treating physician determines a patient needs treatment in the hospital setting, the physician initiates the CMP used by the FQIO by signing the order “Assign Status Per CMP.”

Case management/UR management staff members then have 12 hours to make the initial assignment of the patient’s status using a clinical decision support system, such as Interqual. Some hospitals may resist using CMPs.

“A hospital has to define roles and responsibilities of medical personnel. This is a critical but often neglected task,” Powell says. Nevertheless, “case management is widely used to determine patient status and is becoming more common since the development of the CMP,” she says.

FQIO stated that case managers were not “telling physicians who to admit” under the CMP, but that the protocol requires a physician to sign the order once the physician and case manager agree on the patient’s status.

To get physicians to follow the protocol, FQIO members used physician champions to explain how a chest pain admissions guidance tool, as part of a CMP, can help improve quality of care.

The tool consisted of severity of illness criteria and a decision tree that classifies a patient’s condition and justifies inpatient or observation status–level care. Other important factors of the program were monthly chart reviews, teleconferences, and physician education. Participating hospitals also gave operational definitions of patient status, clinical status, and level of care to case managers and physicians to avoid confusion and potential claims denial.

RAC program’s role in CMP drive

The Recovery Audit Contractor (RAC) program (piloted in March 2005 in New York, Florida, South Carolina, and California) identified $375.1 million in improper Medicare payments during fiscal year 2007, according to a CMS press release.

Medicare is aggressively reviewing cases retrospectively, says Robert Corrato, MD, president and CEO of Executive Health Resources in Newtown Square, PA. Such examinations mean “providers will see a more frequent and critical assessment of their admission status determinations,” Corrato says.

CMS states that it expects to complete the rollout of its nationwide RAC program by January 1, 2010.

“I think the No. 1 push for hospitals to use CMPs would be the incoming [RAC] program,” Powell says.

OIG offers further impetus for CMP

The OIG imposed use of CMP requirements for case manager training and certification at Saint Joseph’s Hospital in Atlanta in a corporate integrity agreement (CIA). The CIA was part of a settlement regarding a recent false claims case in which the hospital inappropriately billed Medicare for short stays.

The hospital soon made changes to its admissions review process, including documentation to validate first- and second-tier review for medical necessity by a physician advisor. The CMP will enable case managers to make admissions decisions with the final disposition of physicians.