Determination of patient stay status, e.g. inpatient vs. observation, is highly important to payers, physicians, and patients alike. Non-Medicare payers perform near concurrent review of admission notes and orders in order to approve the status determination done by the admitting physician. At times, payers will request a change of status. When a status change is made, payers offer a peer-to-peer (p2p) discussion with the attending physician. Physicians are given minimal training for these interactions. Additionally, aggregate results and associated financial implications are often not shared with physicians.
To determine if a structured, multi-disciplinary team could work to improve status recovery in cases challenged by non-Medicare payers within the allotted 72 hour deadline. Status recovery is defined as maintenance of inpatient status (“overturned”) versus downgrade to observation status (“upheld”).
Starting in March of 2016, we identified 9 physicians from within our Hospital Medicine Service (40+ physician FTE) who were willing to handle p2p discussions when they were off service. Each physician is responsible for reviewing an assigned case, contacting the insurance company, scheduling the p2p discussion, and relaying the findings to the SRS Project Coordinator. Each physician was reimbursed hourly market rates for each p2p discussion regardless of outcome.
The institution’s Medical Management Department forwards all denials to the SRS Project Coordinator via email to route to one of the 9 available physicians. Cases are only forwarded for physician review if the admitting physician is employed within the physician group and the insurance’s review process differed with admitting physician over status (inpatient vs. observation). The SRS Project Coordinator collects and tracks data regarding event timing, insurer, reimbursement, and outcome of p2p discussions.
Over approximately seven months, the Hospital Medicine Service spent a total of $22,800 on 152 p2p discussions. On cases where the initial review denied inpatient status and the denial was upheld after p2p discussion the average hospital collection was $3,054. When p2p discussion overturned the initial insurance denial, average hospital collection was $7,645. At an average savings for the hospital of $4,591 per overturned case. The financial impact of the SRS project is approximately $300,000. Limitations include abbreviated baseline data. These findings support the use of designated physicians, within a physician group, to engage in p2p discussions with non-Medicare payers to resolve differences in status determination.
To cite this abstract:Wascome, EJ; Manalac, R; Palermo, G; Slataper, RM . STATUS RECOVERY SERVICE (SRS): A NOVEL APPROACH TO HOSPITAL GROUP-PAYER INTERACTIONS. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 314. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/status-recovery-service-srs-a-novel-approach-to-hospital-group-payer-interactions/. Accessed September 20, 2019.