An innovative case management gatekeeper model for medicare surgeries.
Mary Elizabeth VanGlder1, Elaine Coulter
1Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA. vangelder.mary@mayo.edu
Professional Case Management
|April 16, 2013
Summary
Implementing a registered nurse case manager gatekeeper in the postanesthesia care unit (PACU) significantly improved financial outcomes. This role ensured compliance with Centers for Medicare & Medicaid Services requirements, leading to substantial cost savings.
Area of Science:
- Healthcare Management
- Nursing Practice
- Health Economics
Background:
- The Centers for Medicare & Medicaid Services (CMS) mandates specific criteria for same-day postprocedure surgery admissions to ensure appropriate reimbursement.
- Changes in surgical procedure reimbursement policies present financial challenges for hospitals.
- Accurate patient status determination is crucial for financial viability in surgical care.
Purpose of the Study:
- To identify the necessity of a registered nurse case manager gatekeeper in the postanesthesia care unit (PACU).
- To ensure compliance with CMS admission criteria for surgical procedures.
- To achieve a positive financial outcome through effective case management.
Main Methods:
- Initiation of a case management position within the PACU at Mayo Clinic Hospital, Phoenix, AZ.
- Utilizing the Medicare inpatient-only list for status determination.
- Focusing on compliance with CMS reimbursement requirements for surgical procedures.
Main Results:
- Mayo Clinic Hospital incurred a loss of $357,128 in 2010 due to incorrect status determinations.
- The PACU registered nurse case manager gatekeeper program generated $1 million in savings in 2011.
- Estimated savings reached approximately $1.6 million by November 2012.
Conclusions:
- A registered nurse case manager gatekeeper in the PACU is essential for financial health.
- Effective case management ensures adherence to CMS regulations, optimizing reimbursement.
- The program demonstrated a significant positive financial return on investment.
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