ABSTRACT
Today's environment offers a host of utilization management challenges for healthcare providers. If hospitals are to minimize denials and reduce costs amid these pressures, they will need to adopt several key strategies, including effectively employing use of a dedicated physician adviser.
Subject(s)
Financial Management, Hospital/methods , Insurance Claim Review , Insurance, Health, Reimbursement , Utilization Review/organization & administration , Chronic Disease/economics , Concurrent Review , Consultants , Contract Services/economics , Correspondence as Topic , Forms and Records Control , Guidelines as Topic , Hospitalists , Humans , Patient Transfer , Planning Techniques , United States , Utilization Review/methodsABSTRACT
As hospitals near the end of their third year with APCs and the Medicare outpatient PPS, it's important to reflect on past successes and prepare for the management strategies that will be needed for tomorrow. Particularly important will be reinforcing the importance of interdepartmental cooperation, especially as it relates to new documentation and coding requirements, observation and emergency department protocols, E/M classifications, registration processes, and medical staff involvement.
Subject(s)
Financial Management, Hospital/methods , Medicare Part A , Outpatient Clinics, Hospital/economics , Prospective Payment System , Documentation , Humans , Interdepartmental Relations , Medical Records/classification , United StatesABSTRACT
To encourage proper payment and avoid imposition of penalties by the Office of Inspector General, providers need to prioritize outpatient compliance efforts. Departments should be accountable for reconciling outpatient code editor edit failures. Evaluation and management code assignment should be examined for inter-rater reliability. Transitional pass-through items should be audited routinely; associated coding should be kept current. Consideration should be given to meeting medical necessity requirements, particularly for mental health services.
