SHM Converge Scientific Abstract ePoster Gallery-Partnering Together to Stabilize Our Hospitals

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The document describes a hospital partnership program designed to reduce insurance denials, improve admission status accuracy, and stabilize revenue while remaining compliant with Medicare rules. Rising denials from Medicare Advantage and other insurers have created financial pressure for hospitals, especially when patients are kept in observation status for two or more midnights but should be billed as inpatient under CMS’s Two-Midnight rule.<br /><br />To address this, the program uses physician advisors and hospitalists to review Traditional Medicare observation cases quickly and automatically. Observation patients are screened after one midnight by advisory nurses and physician advisors, who review clinical documentation, vitals, labs, and orders. If medical necessity supports inpatient care, the physician advisor promptly contacts the hospitalist so an inpatient order can be placed before discharge.<br /><br />The initiative was implemented across 84 hospital medicine programs. It reduced long observation stays for Traditional Medicare patients by 56% and generated an estimated $35.74 million in annualized revenue. A proof-of-concept at one 342-bed Midwest hospital showed additional annual revenue of $384,000 for Traditional Medicare and $438,000 for Medicare Advantage patients. For Medicare Advantage cases that still faced denials, 20% were denied when the patient stayed two midnights but did not meet MCG or InterQual criteria; 80% of those denials were overturned through physician advisor peer-to-peer discussions.<br /><br />Overall, the program demonstrates that collaboration between hospitalists and physician advisors can improve compliance with admission criteria, reduce inappropriate observation stays, and significantly strengthen hospital finances.

Asset Subtitle

Chia-Shing Yang

Meta Tag

Author List Chia-Shing Yang, Melissa Buchner-Mehling

Category Innovations

Concept Hospital Admission Status Management

Concept Two-Midnight Rule

Concept Compliance

Concept Denial

Concept Inpatient

Distinguished Non-Finalist

Presenter Organization Sound Hospital Medicine

Presenting Author Chia-Shing Yang

Track Value in Hospital Medicine

Keywords

hospital partnership program

insurance denials

observation status

inpatient admission

Medicare Advantage

Two-Midnight rule

physician advisors

hospitalists

revenue stabilization

admission criteria compliance

Hospital Admission Status Management

Two-Midnight Rule

Compliance

Denial

Inpatient