Background: Accurate coding is paramount to hospital revenue generation and is often supported by a clinical documentation integrity (CDI) team made up of registered nurses and non-clinical coding personnel. Physician-led coding initiatives have demonstrated improvement in case-mix index and clinical documentation. We hypothesized that physician integration into CDI would result in a more robust improvement [...]

Background: As the landscape of health care access and delivery has changed over the past 10 years, areas of coding, documentation, denials management, appeals, and reimbursement have become more confusing to navigate for most physicians delivering direct patient care. The physician advisor is an experienced physician who understands the rules and regulatory issues involving patient [...]

Background: Hospital at Home programs originated as pilot initiatives on a national scale, gaining momentum during the COVID-19 pandemic. The need for reevaluating healthcare delivery systems became pronounced during this period. Kent Hospital in Rhode Island collaborated with key stakeholders, including Blue Cross Blue Shield of Rhode Island, United Health Care, and CMS, to bring [...]

Background: Upon hospitalization, patients are assigned to an inpatient or an outpatient status for the hospital stay. Failure of this status to match the requirements of the Centers for Medicare & Medicaid Services may lead to lost revenue or increased risk of audits and penalties. Timely ordering of observation services for patients with an outpatient [...]

Background: Sound Hospital Medicine (HM) and Sound Emergency Medicine (EM) staff a 385-bed hospital in California. The Utilization Review (UR) nurses in the ER were not following the hospital’s Utilization Management (UM) Plan of doing initial InterQual reviews before the hospitalist wrote the initial admission order because of the focus on disposition from the ER. [...]

Background: A process problem with our MDR process was identified which had exhausted conventional unit-based approaches to improvement. We researched new processes and brainstormed on an “outside the box” approach to the Case Management model and MDR Daily Meetings. The new approach involved a dramatic Hospital-wide change of structure, associated with integration of multiple service [...]

Background: Insurance companies are issuing more denials and causing financial instability for hospitals. On average, hospitals are paid $6,000 less for a patient in outpatient observation status as compared to inpatient status. According to Kaiser Family Foundation Health, the average expense in 2022 for a hospital per inpatient day was $3,025 and is only increasing. [...]