Improving the accuracy of payment classifications through use of a case management protocol

The purpose of this study is to determine if a Case Management Protocol (CMP) improves the accuracy of assignment of Medicare patients to the appropriate payment classification.

MetaStar, Wisconsin's Quality Improvement Organization (QIO), invited Wisconsin hospitals to participate in this project; 19 hospitals did so. A CMP enables physicians to enter an order in the medical record to "admit the patient under the case management protocol" when it is not obvious to the physician whether the patient should be admitted as an inpatient or placed in an outpatient status. A trained case management professional accesses the documentation in the medical record and makes a recommendation to the physician as to the appropriate status. The decision is ratified by the physician in the form of a signed order.

In comparing 1-day inpatient stays as a percentage of all hospital stays in a group of hospitals that considered the use of the CMP, to that same percentage in the hospitals that did not consider the use of a CMP, there was a reduction of 1-day stays for the former group that was significantly (P<.01) greater than for the latter group; the decrease in target payments for the former group also was significantly greater than that for the latter group (P<.01).

The use of a CMP to assign Medicare patients to appropriate payment classifications is an effective method of increasing the accuracy of such assignment.