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Many hospitals have found that putting SIBRs into place is incredibly challenging. The Case Management Society of America’s (CMSA’s) 28th Annual Conference and Expo recently took place in Chicago, and I was fortunate enough to be a part of it. Attracting professionals represented within CMSA’s strategic mission – collaborators across…
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Better ED quality measures, and, ultimately, greater patient satisfaction are among benefits cited. The placement of registered nurse (RN) case managers in the emergency department, with a focus on determining appropriate admission status and making status recommendations to admitting physicians, has proven to be very successful at Waukesha Memorial Hospital…
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If a patient does not have liability for a particular expense, the insurer is similarly absolved of responsibility. The June 14 issue of RACmonitor focused in part on Anthem’s policy regarding coverage of ED services. The relevant article suggested that insured patients should not face responsibility for emergency room bills.…
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Observation is a service, not a status. As we have all seen in recent events on television, choice of words matters. That’s particularly true in the utilization review world. And one word that matters an awful lot is “observation.” I am sure you have all heard this a million times…
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Anthem’s ED policy prompted a Missouri law that defines a medical emergency. The Upshot column in the New York Times on May 19 focused on Anthem’s experiment with denying emergency room visits, arguing that patients should have known that ED care was unnecessary.    One of the anecdotes in the…
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Joint Commission decision on ligature risks raises questions. Hospital surveyors, in particular Joint Commission surveyors, are placing a major emphasis on ligature risks—the risk that suicidal patients will be able to hang themselves in the hospital. From my limited experience, it appears that the Joint Commission may be going beyond…
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Expect denials as the healthcare giant is cracking down on Levels 4 and Level 5 UnitedHealthcare (UHC) will reportedly review and possibly adjust or deny facility emergency department (ED) claims submitted with Level 4 and Level 5 evaluation and management (E&M) codes, with facilities able to submit reconsideration or appeal…
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Lexington Regional Health Center prepares for the long winter night on Christmas Eve. It won’t be dinner as usual tonight. It is promised to be more festive and elegant, with oyster and potato soup as options. Dressed in scrubs and some wearing their whitecoats, they will shuffle into the cafeteria…
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Confusion persists as providers anxiously await facility-specific guidelines from CMS. Did UHC provide to facilities an ED criterion to use when assigning facility ED evaluation and management (E&M) codes to their patients?  Probably not.  Based on this, most facilities have used the Centers for Medicare & Medicaid Services (CMS) instructions…
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Proprietary algorithm to determine “correct” code and change claim. It’s clearly a new age in the coding of emergency department (ED) visits – after all, one insurance giant is reportedly looking to take the human element out of the equation completely. ED facility coding and auditing seems to be a…