Determining Patients Level of Care

Hospitals are often penalized financially for incorrectly determining a patient’s level of care. This level of care is basically a determination of whether the patient is in inpatient or outpatient status. The hospitals level of care determinations can be reviewed for mistakes. Many reviewers exist, such as the Recovery Audit Committee (RAC) and the Medicaid Audit Committee (MAC), and they can levy huge fines—and do so—if they determine that mistakes were made. Other reviewers such as the QIO (Quality Improvement Organization), review hospital cases for accuracy in level of care determination. Though the QIO’s are designed for educational purposes, they do have the ability to refer hospitals for more stringent reviews with RAC auditors if the hospital has ongoing problems with medical necessity accuracy (Figure 4.3).

There are three primary portals of entry which require the presence of a reviewer to determine the patient’s medical necessity and the type of location within the hospital where the patient would be best served: the Emergency Department, the Operating Room or PACU and the Cardiac Cath lab. In most institutions, this person is a care or case manager.

Usually a registered Nurse with prior clinical experience and an ability to review documented data and use clinical decision making to cross reference with some type of guideline such as InterQual or Milkmans [12, 13] (Figure 4.4).

Utilization of reviewers in the three portals of entry can vary. The majority of patients coming out of the Operating

Example where health care organizations are penalized

Figure 4.3 Example where health care organizations are penalized.

Care Management role in determining patient level of care

Figure 4.4 Care Management role in determining patient level of care.

Room and the Cath lab have had a predetermined status.

The case manager’s job here is to determine if that status has changed due to some complication or unexpected symptomatology associated with the procedure. The patients coming from these two portals are predominantly entering the hospital Monday through Friday as surgery and cardiac procedures are seldom scheduled on weekends and off-hours. Rare indeed is the institution that has moved to performing these procedures 7 days a week, 365 days a year.

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