Q&A: Making the case for reviewing all payers

Q: Can someone help with creating a business case covering commercial patients? How does doing so add to the value of CDI efforts?

A: Determine which commercial payers reimburse the facility based on MS-DRGs, say members of the ACDIS Leadership Exchange networking community. Armed with that data, program managers can then dig into the potential financial implications of reviewing these records by comparing current outcomes for the similar volume of Medicare cases, says Lee Ann Landon, BSN, CCMC, CCDS, CDI manager at Honor-Health in Scottsdale, Arizona.

“It won’t be exact, but it will get you in the ballpark,” she says.

At Brigham and Women’s Hospital in Boston, CDI Director Deb Jones, RN, MSN, CCDS, followed a similar path and was surprised to see that some of the payers she assumed would reimburse based on DRGs didn’t. To make the case for additional staff, Jones looked at the number of additional discharges per month of those DRG-based payers against an estimate that a full-time staff person could review 1,900 discharges per month.

“We wanted to air on the very conservative side with our proposals, especially knowing that the patient population was generally healthier than Medicare patients, but the per case financial impact can often me much more significant. We started in September and already exceeded our projections for fiscal year 2019, so that was likely much too conservative. But, better safe than sorry!”

Those looking to expand to other payers need to keep in mind the possibility of additional software vendor fees, Jones says, and watch for any uptick in clinical validation or coding denials related to CDI efforts.

“The other issue is that you provide a consistent message to your providers,” says Landon. “If they are only queried on Medicare cases that does not reinforce your efforts to get them to understand how document accurately.”

Editor’s note: Members of the ACDIS Leadership Exchange group answered this question. If you have questions you’d like to pose to one of ACDIS volunteer boards, committees, or networking groups, contact Associate Editorial Director Melissa Varnavas (mvarnavas@acdis.org), or post it to the ACDIS Forum.