Improving Reimbursement With Nursing Case Manager Status Assignment

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Abstract

Problem:

Historically, physicians completed status assignment during the admission process. Incorrect status assignment of patients can result in reimbursement problems and denial of payment by Medicare, Medicaid, and private insurance companies.

Purpose:

The purpose of this study was to evaluate the impact of case manager's role with status assignment during the admission process by looking at the denial of payment for services rendered.

Methodology:

Denial rates were evaluated for two 15-month time periods: preintervention group (status assignment completed by physicians) and intervention group (status assignment recommended by case managers with physician signature). Denial data for all diagnosis-related groups possessing a more than 2% denial rate related to status assignment were further examined to identify the rationale for denial of payment.

Findings/Outcomes:

The greatest denial rates for payment occurred during the Preintervention Period, when physicians assigned status for patients independently. There was a significant reduction in denial of payment for most diagnosis-related groups during the Intervention time period when case managers were recommending status assignment.

Implications for Practice:

Evaluation of denial data provides an opportunity to target creative performance improvement solutions to reduce denial of payment related to incorrect status assignment.

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