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Related Experiment Videos

Improving reimbursement with nursing case manager status assignment.

Marlyn K Bledsoe¹, Michele L Marshall

¹Center for Status Integrity for Premier Health Partners, Dayton, Ohio, USA. mkbledsoe@PremiereHealthPartners.org

Professional Case Management

|February 8, 2013

Summary

Case managers improving patient status assignment significantly reduced payment denials. This shift from physician-only assignment enhances revenue cycle management and ensures proper reimbursement for healthcare services.

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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.