In today’s highly regulated healthcare system, the management of patient status is a complex, labor intensive process requiring extensive case management expertise. Despite efforts on the part of Center for Medicare & Medicaid Services and other payers to clarify patient status and medical necessity guidelines, hospitals have difficulty reducing denials while maintaining compliance. In addition to the complex regulatory environment, internal approaches to Appeals hinder improvement and management efforts. Often considered a “non-core” activity, the process is excluded from continuous improvement methodologies and training activities. There is a significant lack of robust reporting and transparency into reasons for denials, including the role of Coding and/or Case Manager and Provider documentation. Additionally, Appeals can be resource intensive and as a “non-core” activity, there is pressure to outsource this function.
Our Solution: Patient StatusEdge®
Technology and expert services to help alleviate the burden of managing the patient status audit and appeal process while achieving continuous improvement. Patient StatusEdge® is an innovative online Appeals Management program that simplifies the patient status audit and appeals process while incorporating key metric reporting and continuous improvement training for Case Managers, Providers, and Coding staff. Use Patient StatusEdge® to assess and improve the effectiveness of Case Managers and internal or outsourced Appeal Writers. Or, bring the entire Appeals Management process in-house by using Patient StatusEdge® to manage workflow and improve outcomes from the first request for information through final appeal. In either case, Case Management departments can utilize Provident’s expert clinical and compliance team to assist as needed with implementation, training, auditing, and appeal services. Electing Provident’s consulting services with Patient StatusEdge® enables hospitals to manage their workflows while learning how to transition to fully independent, best practice programs. Our comprehensive solution includes:
- Provident’s Patient StatusEdge® technology
- Automated timeline representing medically necessary hospital care
- Appeal templates and exhibits
- Clinical and legal reference libraries
- Strategic guidance for drafting appeals or outsourced appeal writing
- Comprehensive medical record reviews
- Customized clinician training
- Data analysis, trending and reporting
A COMPREHENSIVE APPROACH
Provident brings continuous improvement to healthcare through its suite of Technology-Enabled Clinical Solutions™. Patient StatusEdge® delivers this for the patient status audit and appeals process. An annual subscription to the web-based tool provides hospitals with the workflow, tools and forms needed to efficiently produce well written and effective appeals. Our easy to understand tutorial, strategic guidance, and legal and clinical references guide clinicians through the appeal writing process from beginning to end. Patient StatusEdge® includes on-demand training, auditing functions and the ability to continually assess staff proficiency.
- AUDIT: Evaluate the effectiveness of your case management program using inter-rater reliability testing and built-in auditing tools. Identify opportunities and trends to improve provider documentation and support admission status compliance.
- EDUCATE: Train staff using Provident’s built-in education modules, resources and reference library. Audit findings are used in Patient StatusEdge® training examples to increase adherence to documentation standards and reduce queries and denials. Training examples are delivered directly from the Patient StatusEdge® tool to staff’s inbox for targeted training of case managers, providers, physician liaisons and clinical documentation improvement specialists ensuring continuous process improvement.
- APPEAL: Produce well-written, accurate, and comprehensive appeals in less time at a lower cost using Provident’s tools, templates and reference libraries. Create concise visual representations of the patient’s plan of care to help justify patient status and highlight key events during the patient’s stay.
WHAT SETS US APART
Provident’s depth of experience in clinical services, healthcare operations, compliance, data analysis, and revenue cycle makes us uniquely qualified to provide valuable analysis and guidance. Our team members have professional backgrounds working in provider organizations, law firms, and government agencies. We have unmatched knowledge of organizations across the healthcare spectrum, from single hospitals to healthcare systems, academic medical centers, and physician practices.
Audit. Educate. Appeal.