HealthSystems Management Network believes that the Utilization Review staff
can better serve the patient, payor and institution by taking a proactive,
rather than reactive, quasi-regulatory role. This role is supported through
the creation of a patient documentation system that is a dynamic and interactive
medium for communication. The end result will be not only effective case management,
but the quality management of hospital resources as a whole.
Simply put, it is far better to predetermine the appropriateness of services than to be refused payment by regulators or third-party payors after the services have been rendered. Right now, your Utilization Review staff has the basics to help assure that hospital revenues are matched to the use of hospital resources. Health Systems Management Network canp rovide the Utilization Review staff with the keys to effective case management:a benchmark-oriented case management system and a dynamic documentation system. As early in the case as possible, the UR staff, given its knowledge of the regulatory requirements, can provide documentation to the care providers indicating which hospital services are acceptable. In turn, the care providers can document for the UR staff the severity or complications that will affect reimbursement.
Hospitals are created to respond to the needs and crises of their community. This does not mean, however, that the control of hospital resources should be relinquished to vagaries of community support, medical staff and family dysfunction. Rather resource use should be matched to patient acuity and severity of illness. However, Health Systems Management Network often finds that resource use exceeds the acuity need because of the lack of a resource management program. The potential for additional revenue through resource management is substantial. Health Systems Management Network can develop an effective case management system that will help assure that all staff will be aware of and work toward "benchmarks" of care while maintaining a high quality of service to patients.
Health Systems Management Network can analyze an entire year of patient demographic and payment data to understand provider patterns of resource utilization and its documentation. In addition to this retrospective review, we will perform a concurrent review of a number of actual patients to determine,with the assistance of the staff directly involved with the care, the quality of documentation and DRG assignment, severity assignment, reasonable expectationsfor length of stay and ancillary usage and the discharge planning process.The analysis of these data will result in systems designed to encourage the appropriate use of hospital resources and improve patient access. OurCase Mix Analysis will furnish factual information about:
As benchmark-oriented case management systems with their new emphasis on interactive documentation are implemented, the level of communication and cooperation among the entire healthcare team is significantly enhanced. Health Systems Management Network has found that excellent communications are the key to improved quality of care and reduced risks of poor performance and audit loss.
