Patient status: focus on the case, not the criteria

In healthcare, one word bears a startling amount of baggage, both in terms of relationships and finances: inpatient. Criteria seek to define it; utilization review seeks to confirm it; reimbursement follows it. For something so elemental, it is also elusive.

Medicare’s 2MN requirement has been the standard litmus test for years now, but as with the ever-changing healthcare landscape, standards may change based on repetition, habit, and expectations. What do I mean? I mean that as some health plans have raised pressure on providers in terms of documentation and procedure around inpatient determinations, not even traditional methods of determination – screening criteria and tools – are a surefire way to correctly assess status (though I might argue they never were). Indeed, with 30% of hospital reimbursement leaders citing medical necessity inpatient as their top concern for denials, something has to give.

My advice to providers is simple: it was always about the clinical merit of the case anyway, so review strongly, determine wisely, and appeal accordingly. Analytics can play a huge role in this process: by assessing each case independently but in the context of “bigger data,” they can give clinicians the kind of insight they need to make the right choice every time. Use analytics tactically to help remove the administrative burden of data gathering and strategically to build a complete picture of the gaps where friction occurs and revenue leaks.

Up front, shore up your documentation, focus your tools and analytics on the holistic clinical picture of the patient, and let your staff know that “green light shopping” isn’t a sustainable strategy – they should be afforded the tools and time to dig in on their cases and make a strong showing for their determinations. If a denial occurs, the appeal should also focus on the clinical merit of the case, not the tool used or the output arrived at.

Inpatient status should be about the patient, not the process. Let’s lessen that baggage, build those bridges, and ensure that smart + sustainable isn’t an elusive goal.


Hear more from Kelly Layton, former client turned colleague, on this topic below: