In a recent article, Dr. Hirsch said these staff members encounter a number of hurdles before a patient is even admitted, when the physician or hospital staff tries to pre-certify services. Also, for emergency admissions, the hospital case management staff must call in the admission within 24 hours to provide clinical information and to try to get approval for the admission, Dr. Hirsch writes. And, he said, some commercial insurers now have outsourced their hospital admission notification process to offshore companies, which can only receive information and not approve any admissions, adding another delay.
However, Dr. Hirsch outlines various ways that hospital finance staff may help their patients and the hospital’s case management workers.
Here are five pieces of advice from Dr. Hirsch.
1. Let case management staff give their input during contract negotiations with insurers.
2. Ask certain questions when negotiating a contract. These include the following: Does the plan have a provision for concurrent admission reviews? Are the authorizations for admission binding? What admission criteria are used? What is the time frame for retrospective reviews? Is there any limit to the number of charts in audits? If so, is it absolute or a percent? Is any payment made to the hospital to copy charts?
3. Make sure the contract is specific as far as what criteria are used to determine approval of inpatient admissions and how the criteria are used.
4. Review the denial appeal process for inpatient admissions and outpatient testing.
5. Finance staff should also insist that billing and payment for readmissions are clearly outlined in contracts with insurers.
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For-profit hospital stock report: Week of May 11-15
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Engagement with community physicians
