Improving reimbursement with nursing case manager status assignment

Area of Science:

• Healthcare Administration
• Health Services Research
• Revenue Cycle Management

Background:

• Physician-led patient status assignment historically caused reimbursement issues.
• Incorrect patient status assignment leads to payment denials from payers like Medicare and Medicaid.

Purpose of the Study:

• To assess the impact of case manager involvement in patient status assignment.
• To determine if case manager recommendations reduce payment denials during admissions.

Main Methods:

• Comparative analysis of denial rates over two 15-month periods.
• Pre-intervention: physician-assigned status. Intervention: case manager-recommended status with physician signature.
• Focused analysis on diagnosis-related groups with >2% denial rates.

Main Results:

• Higher payment denial rates observed during the pre-intervention period.
• Significant reduction in payment denials during the intervention period with case manager involvement.
• Case manager recommendations correlated with fewer denials for most diagnosis-related groups.

Conclusions:

• Case manager involvement in patient status assignment is effective in reducing payment denials.
• Data-driven evaluation of denials can inform performance improvement initiatives.
• Optimizing patient status assignment improves healthcare revenue cycle management.