Missing adequate weekend assessments exposes up to 29% of hospital days to potential payment issues. Physicians consider many factors during the complex clinical judgement used in determining a hospital admission. Many hospitals operate with reduced staffing on the weekends, and this can have a significant impact on reimbursement when factoring that weekends encompass approximately 105 days a year. Appropriate level of care (LOC) status is not always clear-cut, and a patient’s condition can change over time, making LOC determination a time-sensitive and a revenue-sensitive decision, no matter the day. AppriseMD lays out the sizeable financial impact of forgoing weekend assessments in the white paper linked here.
To illustrate how much revenue can be lost on weekends, consider the Healthcare Financial Management Association’s (HFMA) estimates for “a standard inpatient case that may be reimbursed at about $6,500, based on CMS regulations, compared with $2,000 for a standard observation discharge.”1 HFMA notes, “there is a $4,500 variance for a case that might have received the exact same care but was discharged with an inappropriate status.”1 Such a significant variance reinforces the importance of ensuring appropriate LOC status daily, as misaligned care statuses will always equal reduced revenue. For example, if a physician advisor’s medical necessity determination recommends a change in the LOC from observation to inpatient, then the hospital realizes a potential opportunity to maximize their reimbursement. This determination more than doubles what they would have collected based on the information from HFMA. Equally, a recommended move from inpatient status to observation status represents a potential avoided denial.
AppriseMD evaluated its client utilization review trends to uncover the impact of weekend reviews. Using Q2 data from 2023, a client with approximately 15,000 annual discharges realized 112 LOC recommendations on the weekends, with 63% representing a suggested LOC change from observation to inpatient. The remaining 36% of cases were LOC suggestions from an AppriseMD physician advisor recommending that the patient be transferred to an alternate location such as a skilled nursing facility (SNF) or home. Both of these recommendations enabled the hospital to free up bed availability while also contributing to staff productivity. From a financial perspective, all 112 LOC recommendations on the weekends in just one quarter resulted in $495,000 in potential revenue.1
See more examples of how admission status translates into revenue here.
SOURCE
- Goode, Jeffrey, MD; Burke, Dan; Harper, Ben; and Richards, Barton S, “How to determine appropriate patient status and navigate observation-level care,” Healthcare Financial Management Association. March 16, 2023.