• Case #1: 300+ Bed Acute Care Hospital
• Case #2: Managed Care Health Plan
• Case #3: 350+ Bed Acute Care Hospital
• Case #4: Pharmacy and Supply Company

Case #1: 300+ Bed Acute Care Hospital

Goal: Assess documentation/compliance of the medical necessity of one-day stays.

Project Specifics: 

• Review of over 100 one-day stay records via remote access.
• Required expertise in Milliman Care Guidelines.
• Provide case-by-case report.
• Turn around time – four days.

Services Provided:

• Objective review based only on criteria.
• RN with over ten years experience using Milliman Care Guidelines.   
• Detailed report identifying cases that did not meet criteria and why.
• Identification of potential trouble areas.

Outcome:

• Data provided to support need for additional education.   
• Ongoing review requested to monitor compliance.
• Successful completion of all project specifics within the required timeframe.

Case #2: Managed Care Health Plan

Goal: To determine if patients’ presenting symptoms to EDs are appropriate for treatment.

Project Specifics:

• Review of over 200 ED patient encounters.
• Collect data using electronic data collection tool.
• Conduct provider survey calls.

Services Provided:

• Experienced nurse data abstractors with over six years average experience.

Outcome:

• 93.3% overall reliability.

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Case #3: 350+ Bed Acute Care Hospital Needing Help with a Coding Backlog

Goal: Decrease backlog of inpatient records.

Project Specifics: 

• Experienced inpatient coder to work onsite.
• Needed two days a week until appropriate staffing level is reached.
• Must pass in-house coding test.
• Fill immediate need.

Services Provided:

• Next day service.
• CCS with over six years of inpatient coding experience two days a week.

Outcome:

• Coding backlog eliminated.
• Relationship and trust developed between contract coder and hospital.
• On-going coding support.

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Case #4: Pharmacy and Supply Company

Goal: Assess all claims for compliance with medical necessity and accuracy of coding, submission and reimbursement. 

Project Specifics: 

• Expertise in billing, coding, reporting, medical necessity and Federal guidelines.
• Reviewer must have nationally recognized coding certification.
• Knowledge of appropriate statistical sampling techniques.
• Preparation of a timely report.

Services Provided:

• RHIT, CCS, CPC-H with over 20 years experience.
• BS (Mathematics-Statistics and Economics) MPA, Certified Quality Process Analyst with over ten years experience to conduct the statistical sampling plan and analysis of data collected.
• Observations, findings and recommendations on possible improvements to the system(s) and process(es) that generated errors in compliance review.

Outcome:

• Successful completion of all project specifics within required timeframe.

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