SHM Converge Scientific Abstract ePoster Gallery-Partnering With the Hospital: Pilot for Proof of Concept

Pdf Summary

The document describes a pilot program at a 385-bed California hospital aimed at improving admission-status accuracy and reducing insurance denials by better aligning hospitalist admission orders with InterQual medical necessity criteria.<br /><br />The hospital’s ER utilization review (UR) nurses were focused on patient disposition and often did not complete initial InterQual reviews before the hospitalist entered the admission order. This created misalignment between the status ordered at admission and the centralized UR team’s later Day 1 review, leading to extra work, more physician-advisor involvement, and higher denial rates. The hospital wanted to maintain compliance with CMS Conditions of Participation while reducing denials and unnecessary observation stays.<br /><br />Sound Advisory took over the initial InterQual reviews remotely, staffing LPNs and RNs 24/7 and training them through videos and handouts. ER clerks notified hospitalists by TigerText and included the reviewer’s name. Hospitalists then entered admission orders based on the InterQual recommendation, with special attention to Medicare fee-for-service patients and anticipated length of stay. The team also created a process to automatically identify Medicare observation patients after one midnight and have physician advisors review those staying a second midnight to ensure compliance with the 2-midnight rule.<br /><br />Results showed a significant reduction in patients needing escalation review and a drop in Medicare long observation stays from 14.4 to 6.3 per month. The program improved alignment between admission status and level-of-care criteria, supported provider education, and was estimated to increase annual revenue by about $578,000 through better reimbursement and reduced denial risk.

Asset Subtitle

Chia-Shing Yang

Meta Tag

Author List Chia-Shing Yang, Melissa Buchner-Mehling

Category Innovations

Concept InterQual Initial Review

Concept Admission Status

Concept Medical Necessity Criteria

Concept Utilization Review

Concept Level-of-Care Criteria

Distinguished Non-Finalist

Presenter Organization Sound Hospital Medicine

Presenting Author Chia-Shing Yang

Track Value in Hospital Medicine

Keywords

InterQual

admission status accuracy

insurance denials

hospitalist admission orders

utilization review

CMS Conditions of Participation

Medicare 2-midnight rule

observation stays

physician advisor review

hospital reimbursement

InterQual Initial Review

Admission Status

Medical Necessity Criteria

Utilization Review

Level-of-Care Criteria