Hospital offers incentives for identifying incorrect patient status

It’s no secret that hospitals struggle with assigning the most appropriate status for patients, and this challenge is compounded by CMS’ frequent changes to its regulations and guidance. To combat incorrect patient status assignments, one hospital has developed a system that rewards employees for speaking up when they suspect a patient’s status is incorrect.

After an assessment of its HIM department, Montrose (Colorado) Memorial Hospital began an informal program focused on providing patient status education for physicians and engaging various departments throughout the revenue cycle in identifying whether a patient’s status is correct.

The hospital had a long-standing problem with helping physicians understand how to correctly determine patient status throughout the patient’s stay. For example, some providers would change a patient’s status from inpatient to outpatient at the last minute if a patient seen for an inpatient-only procedure recovered quickly and could return home after one night, incorrectly assuming that a stay of one midnight?regardless of the procedure type?could not be an inpatient stay. This left other hospital staff members scrambling to change the patient’s status back to inpatient or face a potential denial, says Bev Roth, BSN, case management director at Montrose Memorial Hospital.

"I tried education. I tried to pull in other departments to help," Roth says. "Case management was the lone outfielder trying to catch the fly ball before the patient went out the door."

As more and more providers began throwing up their hands, the hospital decided to take action by bringing HIM, case management, and other departments together to address the issue head on. Some departments felt that tracking patient status was not their responsibility, but Roth sought to ensure each department involved in the patient’s care could help protect the correct status, thus ensuring the patient’s insurance would be billed correctly and the hospital’s claim filed appropriately. "How do you get over the hurdle of people feeling like that type of activity is not their job?" she says.

Roth began developing cheat sheets for physicians to help them differentiate between inpatient, inpatient-only, and outpatient stays. She also worked on educating the hospital’s clinical counsel, which includes all of the directors who are directly or indirectly involved with patient care, on patient status. But because getting physicians to adhere to patient status regulations was an ongoing challenge, simple education would not be enough. For this reason, Roth focused on bringing together each department that worked with the medical record and training them to act as watchdogs, keeping an eye out for incorrect patient status assignments and changes.

The workgroup

The hospital established a workgroup that brings several departments (e.g., patient access, case management, HIM, utilization review [UR], coding, patient financial services, clinical documentation improvement) to the table and maps out how each one impacts patient status, says Jane Bonewell, RHIT, CHDA, senior consultant for the Haugen Consulting Group in Denver. For example, patient access would discuss the importance of patient status at pre-authorization, pre-registration, registration, and scheduling. This department is important because it follows the patient’s journey from beginning to end, but so are departments like case management and UR, which follow the patient through the middle part of his or her journey, as well as HIM, which tracks the medical record, Bonewell says. If the patient’s status isn’t right from the beginning?often the point when patient access is involved?problems may arise down the line.

"As we all know, we can get all the way from patient access to patient financial services with the incorrect patient status," Bonewell says. "In order to circumvent that from happening and fixing things on the back end or before we drop the bill, we’re trying to work through those middle pieces so that we can get it right by the time the patient is discharged."

As the workgroup walks through the patient journey together, each department often experiences "aha moments." Opening the lines of communication between the departments and allowing each to fully understand its role, as well as the role of others, can help people understand why their tasks are important not only for their own job, but also for others involved with the patient. "It’s been a really good educational process," Bonewell says.

The reward system

Through the case management department, Montrose Memorial Hospital developed a strategy to reward staff members for bringing a possible incorrect status assignment to the attention of the UR staff.

"We created awareness. We did the education," Roth says. But what next? To incentivize the staff to bring incorrect patient status to light, the hospital opted to use gift cards to an on-site coffee shop.

"I really wasn’t expecting a whole lot out of that. I didn’t think necessarily a free coffee was going to be the big answer to the problem," Roth says. Although some departments were resistant, she decided to roll out the incentive for case managers. Other departments soon followed suit as she began making the rounds and striving to better understand how each department works with and understands patient status. After spotting an incorrect status, staff members can call a hotline that connects them with a UR staff member who is on call for that day. UR will then review the record for medical necessity to determine whether the status is correct.

Employees can also alert the UR staff when a patient should be transitioning to a different status, Bonewell says. For example, if a patient has transitioned from outpatient to inpatient but his or her medical record still reflects outpatient status, an employee can alert others to this discrepancy and be rewarded for his or her efforts.

Often, the UR director will speak with the provider after completing the record review and view the discussion as a clinical documentation improvement opportunity as well as a way to validate patient status. "It gives them the opportunity to have those face-to-face, difficult conversations with the provider," says Bonewell. "They’re talking about options and what we can do to protect the patient and the facility." This face time with the provider is preferred over a phone call because it supplies more opportunities for education and communication. For example, if the patient’s condition is not severe enough to warrant hospital-level care, this meeting time can allow UR and the physician to discuss options for transfers or homecare, or to reach out to the patient’s family for exploration of other options.

Providers are encouraged to contact UR or case management for a status determination on their own cases, although the majority of cases are reported by the nursing staff. "It’s turned into this competition among the staff, and some providers are encouraging their peers to take advantage of the program," Bonewell says.

Regardless of whether the person alerting UR to look into a case was right about a patient’s status needing to be changed, he or she is still rewarded with a gift card, Bonewell says. If a provider is sitting on a unit or in a hospital lounge, the UR staff will often deliver the provider the coffee of his or her choice rather than presenting a gift card. This helps spur competition because the providers notice when their peers are rewarded. "They compete with each other for who is going to get their coffee delivered that morning," says Bonewell.

"It’s an informal program, but everybody gets a big chuckle out of it when you bring the [gift] card by," Roth says.

While the competitive nature of the program has helped it gain awareness and encouraged providers and others to bring attention to incorrect patient status assignments, the real measure of success is that the program has led to changes in status that could have been problematic if not identified prior to discharge, Bonewell says. In addition, it heightens awareness of problems associated with incorrect patient status, educates hospital staff members on what each status means, and gives UR or other hospital staff members the opportunity to have conversations with providers.

Most importantly, it has aided the hospital in catching incorrect patient status early in a patient’s stay. Getting the hospital’s physician champion involved in the incentive program also helped with physician buy-in. "He really backed me up," Roth says.

With 75 inpatient beds, Montrose Memorial Hospital is smaller than some inpatient facilities, so it has been relatively easy to raise awareness about the workgroup and rewards program. However, Bonewell notes that ­Montrose’s strategy could also take flight at larger facilities.

Analyzing trends

Roth says she is currently tracking the metrics for self-denials, although since Montrose Memorial Hospital is still focusing on education and communication, it’s not yet at the point where it can use data from the program to analyze the effort’s impact on patient status and denials.

A program such as this could be used to measure a hospital’s denials and potentially avoid a high volume of denials further down the line. It could also help hospitals progress toward assigning the correct status or pinpoint the most common mistakes when assigning or changing patient status. When the program is more mature, the UR staff may be able to report statistics from the workgroup at section meetings. At the very least, the workgroup should be prepared to share statistics about the number of hotline calls and potential patient status errors at each of its meetings, Bonewell says.

Bonewell notes that Roth’s initial goals were not just focused on getting patient status right at Montrose Memorial Hospital, but also offering staff and providers the education and tools to consider patients’ needs after they leave the hospital. She admires Roth’s commitment to ­better connect the hospital with the community to help patients tap into post-discharge resources.

"Where I see her going with this is something pretty unique that I haven’t heard happen?and part of it is because it’s a smaller community, but that’s not to say you can’t do that in a big city," Bonewell says. "There are so many resources out there that we never tap into that we can start to educate our providers on."

Roth agrees that connecting with staff and providers individually has made a difference. "This program really developed out of desperation. We had been unsuccessful previously to get buy-in on the importance of correct patient status. Taking the time to deliver a personal thank-you which rewarded them for being a patient advocate was the key," she says. "We now like to say we’re changing the world, one cup of coffee at a time."

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