The Utilization Department covers Utilization Review, Case Management, Social Services, DME Indigent Program, Prescription Assistance Program and the Swing Bed program.
Utilization Review & Case Management (Vicky Rasberry & Wendy Davis) – Works to ensure that medical care is effective, efficient and in-line with evidence-based standards of care. These reviews help determine the medical necessity of procedures as well as recommendations for alternative care or treatment. Third party payers (Insurance/Medicare Advantage Programs) require clinical information to be sent to them proving medical necessity for payment. If clinical information is not provided in a timely manner, they can deny payment. If they determine the patient should be under Observation care but the order is for Inpatient, they will deny payment. If they decide the diagnosis provided by the physician does not match the clinical picture, they can downgrade the diagnosis and pay a lesser amount. We currently have 42 accounts that are under appeal for denials of either partial or full payment.
Did you know…. Your clinical documentation helps to determine payment for services rendered. Your documentation is utilized to demonstrate that each patient is ill and needs to be cared for in the hospital. So, when you see your provider documenting about your signs and symptoms they see, hear or smell could make all the difference in the hospital reimbursement. We want our patients to be well but if our documentation paints a picture of wellness instead of illness, payment for services is in jeopardy. Payers want to know that they are paying for necessary services. When documenting, all the specific details do make a difference.
Social Services (Teri Wilson) - Not only provides services to hospital patients but also assists the physician’s office as well as the community at large. Patients are screened to help determine their abilities as well as help resolve social and environmental issues affecting their health. Assist with their discharge needs which may consist of caregivers, home health, rehab, nursing homes or assisted living. They also make referrals for the Ramp project – assistance in getting the elderly or disabled residents ramps built for entry/exit of their homes.
DME program (Abigail Chadwick) - Helps provide DME equipment to Nolan County Residents that are unfunded or under insured that would otherwise not be able to obtain the needed equipment. It is also available to patients discharging from the hospital that may be experiencing a delay in insurance approval. This assistance helps prevent a delay of discharge.
Prescription Assistance Program (Debbie McIntire) -Aids Nolan County Residents or clients using local physicians. These medications are provided by pharmaceutical companies to qualifying individuals. This program is a service to the community provided by the hospital. These are medications these clients would most likely have to do without due to the expense if it were not for this program. Over the past 12 months the program has been able to assist with medications worth a retail value of approximately $191,000.
Swing Bed program - Allows Medicare patients that are no longer acutely ill but not yet ready to return home or the next level of care to remain in the facility receiving services to assist them to that next level. Medicare Inpatients are paid by DRG (Diagnostic Related Group) which each DRG has a set payment amount. Regardless of the amount spent, the DRG payment is what reimbursement will be received. However, if the patient qualifies for continued care in Swing bed, the hospital will receive payment based on a RUG (Resource Utilization Group) with a daily payment rate. These RUGs are determined by nursing care, amount of assistance the patient requires,1 assistant or 2, patient ADL abilities, and all rehab services. Once again, documentation makes all the difference in reimbursement.
