Blog, Revenue Cycle, The Hospital Finance Podcast®

The Impact of Utilization Management in Readmissions Webinar [PODCAST]

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In this episode, Meliza Weiner, BESLER’s Senior Manager of Revenue Cycle and Clinical Review Nurse, gives us a glimpse into the upcoming webinar – The Impact of Utilization Management and Readmissions – that will be held on Wednesday, April 19, at 1 PM ET.

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Highlights of this episode include:

  • Overview of readmissions
  • Factors involved with readmissions
  • What is utilization management?
  • How utilization management plays a role in reducing readmissions

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome back Meliza Weiner, BESLER’s senior manager of revenue cycle and clinical review nurse. In this episode, Meliza will give us a glimpse into the upcoming BESLER webinar – The Impact of Utilization Management and Readmissions – that we’re hosting on Wednesday, April 19th at 1:00 PM Eastern time. Thank you for joining us today, Meliza.

Meliza Weiner: Oh, thank you for having me again, Kelly.

Kelly: Great. Well, let’s jump in today. So, most of the people in our audience will be familiar with readmissions and utilization management. So why don’t we just start first with a brief overview of readmissions?

Meliza: Okay. That sounds good. So, I like to start from the beginning first, so let’s start with the foundation. Let’s talk about admission first. So, admission can be defined differently based on how it is used. So, for the purpose of our discussion, since we’re talking about healthcare and hospital – that’s the context we’re going to be using it – admission really means the process of entering or having permission to enter a place like a hospital or a clinic or a treatment facility. That’s basically the base definition by Merriam-Webster and Oxford Dictionary. Now, hospital readmissions is when a patient has been discharged from a hospital and ends up being admitted again to a hospital within a specified time frame. And there are two ways – should we say categories? – on looking at readmission. One, is it avoidable? And two, is it unavoidable? So, the first one I want to talk about is avoidable readmission – sometimes we call them preventable readmissions – and these are patients that were discharged from a hospital and then readmitted again within a specified time frame, whether it be 30 days, 60 days, or 90 days. And the example I like to use is congestive heart failure. Congestive heart failure basically is a patient goes into the hospital with that diagnosis, and then they got discharged, and then they got readmitted again to a hospital – it doesn’t have to be the same hospital – with congestive heart failure again. So that’s something that we consider as it could be avoidable because you can prevent it from happening because congestive heart failure is a chronic condition, which can be managed, and it’s a matter of looking at any interventions that could have taken place that could have prevented the patient from being readmitted.

The second category is the unavoidable or the non-preventable readmissions. And keeping with the same example, you have the patient that came in with congestive heart failure, they get discharged, they got readmitted within – I don’t know – 15, 20 days, this time because they were a passenger in a car and ended up with multiple fractures from a motor vehicle accident. So that’s something that you can’t avoid from happening. And the reason why I say fractures from a motor vehicle accident because if that patient actually was walking outside and then falling, end up with a fracture, the question now becomes, “Was it because of a medication from the congestive heart failure that wasn’t really regulated, or they got dizzy?” So again, you got to look at the circumstances surrounding that readmission whether to define it as is it avoidable or not avoidable. Now, CMS notes that hospital readmissions are admissions to an acute care hospital within 30 days. So that’s the time frame CMS defines it at. So hospital readmissions are really used as quality indicators for treatment effectiveness, coordination of care, follow-up, and transition. So, in fact, the Agency for Healthcare Research and Quality noted that reducing preventable readmission is a national priority for payers and providers and policy makers that are seeking to improve healthcare and lower the costs, which is basically a definition of healthcare reform.

So really, Kelly, what is important to note here is that CMS Hospital Readmission, the Reduction Program, which started in 2012, is now reducing payments to any hospital that participate with the Inpatient Prospective Payment System. If they have an excess of readmissions compared to the national average for that specific applicable condition – and there are five conditions that CMS is looking at – there is a 1-3% penalty on reimbursement. So, in fact, the latest data that CMS has brought out, there are 30-plus hospitals that receive the highest readmission rate penalty, which means they’re actually already seeing a 3% decrease in their Medicare revenue. And because of that, this is now a measure that’s being used by other organizations like the Medicare Accountable Care Organizations. Your Medicaid programs are now looking at it. So, in essence, really, there’s a lot at stake with readmissions. And I hate to say it, but readmission comes with a price, so. That – I would say – is a brief overview of readmissions.

Kelly: Wow, that’s a lot of great information. Thank you. And there are so many factors involved with readmissions. How do you even start?

Meliza: Well, you know what? I think, first, let’s talk about organizational alignment. I think organizational leadership, both administrative leadership, and you have to also include medical staff leadership, your clinical leadership, they need to champion this cause. Readmission reduction has to be a priority within the organization. And once you have that commitment with department heads, and you’ve identified that commitment, and you’ve got that, then you will have complete buy-in from the rest of the organization and departments. Then I think the next thing they have to do is take a look at is the data. I mean, nowadays, you can’t say you have no data. There’s so much data out there, it’s not even funny. You have the technology that holds the data. So, taking a look at the data, specifically start off with looking at the CMS because CMS, it’s publicly reported. So, there’s already a report out there about your own organization, your own hospital. So, look at that data. There are hospital-specific reports, which are being sent out annually, the Provider Participation Report that’s being sent out quarterly. So, you can’t say you don’t have data. Just bear in mind that this data from CMS is a two-year lookback. So again, when you’re looking at it, just keep in mind the data, the time frame that you’re looking at in order for you to create your intervention. And then I think the third step is now creating your intervention because once you’ve looked at the data, you know your numbers, you’ve analyzed it. Then you can take a look at where you’re going to focus. What strategies do you need to start tackling the readmission? Do you need screening tools like LACE? Do you need to work with programs like Project BOOST or Project RED or Care Transitions? So, I think those are the three key factors to take a look at in order to start tackling readmission reduction.

Kelly: That makes a lot of sense. And utilization management is a topic that comes up when discussing readmissions, but what is utilization management?

Meliza: So funny that you’ve mentioned that because I get a lot of questions about that. Institute of Medicine and the Utilization Review Accreditation Commission tries to define utilization management. But I would like to use two organizations that are so in tune to case management and, should we say, that the case managers and utilization managements are familiar with. It’s the Case Management Society of America. They actually define utilization management as ensuring the appropriate allocation and use and coordination of healthcare services and resources while striving to improve safety and quality. The American Case Management of Association also defines it as they’re expected to advocate for the patient while balancing the responsibility of stewardship for their organization and especially looking at judicial management of resources. So basically, in a nutshell, utilization management encompasses a diverse set and group of techniques and activities that are designed to influence the use of healthcare resources.

Kelly: Makes sense. And so how does utilization management play a role in reducing readmissions?

Meliza: So, utilization management department, they typically interact with all, if not most, of the hospital operations services. They work with the healthcare team. Utilization management department can facilitate and coordinate resources and services in a quality-conscious and cost-effective manner. For example, they review claims, they review charts, they review the cases before they get to the hospital, while they’re in the hospital, after they get discharged from the hospital. But I want to focus on while they’re in the hospital. When they’re looking at these cases, and they’re looking at these patients, they’re actually looking at the medical necessity for those procedures. Should it happen? Was it supposed to happen? Did it happen? And while they’re doing that, they can work with departments and work on referrals for social work, for pharmacy, for physical therapy, and with that, they can start looking at intervention and develop a plan so when the patient gets discharged, there’s a plan in place that’s going to prevent them from actually coming back into the hospital because they’re not able to manage themselves as they transition out of the hospital. Utilization management also works with the quality department. They actually have access to that data. Quality department is basically the portal that holds all the information from quality measures and CMS, and they can look at patient care systems. They can evaluate them and look at the standards and the protocols and documentation in order to help facilitate the transition of patients from the hospital to outside of the hospital. So, in essence, really, this integration of utilization management and its process within hospital operations can actually increase care efficiency and also decrease revenue loss, let’s say, from readmissions.

Kelly: Wow, that’s a lot of great information. Thank you so much, Meliza. Thank you for joining us today and for sharing everything leading up to the upcoming webinar – The Impact of Utilization Management and Readmissions – you’re doing live on April 19th, 1 PM Eastern. Thank you so much.

Meliza: You’re welcome.

Kelly: And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of the Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit The Hospital Finance Podcast is a production of BESLER | SMART ABOUT REVENUE, TENACIOUS ABOUT RESULTS.


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