An Innovative Case Management Gatekeeper Model for Medicare Surgeries


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Abstract

Purpose/Objectives:This article identifies the necessity of a registered nurse case manager gatekeeper in the postanesthesia care unit (PACU) at Mayo Clinic Hospital, Phoenix, AZ. The Centers for Medicare & Medicaid Services have mandated certain criteria regarding the status of same-day postprocedure surgery hospital admissions that must be adhered to in order to receive appropriate reimbursement for surgical procedures. The changes in reimbursement for surgical procedures have become more challenging. To receive optimal reimbursement for surgical procedures, Mayo Clinic Hospital initiated a case management position in the PACU to ensure compliance with the Centers for Medicare & Medicaid Services requirements. This article discusses how the case management role was developed using the Medicare inpatient-only list status determination to achieve a positive financial outcome.Primary Practice Setting:Acute care hospitals that perform surgical procedures.Findings and Conclusions:In 2010, Mayo Clinic Hospital sustained a loss of $357,128 from incorrect status determinations and orders. In 2011, the PACU registered nurse case manager gatekeeper program achieved a savings of $1 million. The estimated savings for 2012 through the end of November is approximately $1.6 million.Implications for Case Management:This article addresses the following:The RN gatekeeper position criteria and detailed steps for beginning a PACU case management program,management and organizational action plans,the necessity of ongoing education of staff and physicians and the development of rapport with PACU staff, andexamples of case management interventions and cost savings.

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