The People’s Choice Hospital Revenue Enhancement now offers consulting services which directly focus on capturing lost revenue and reducing CMS (Centers for Medicare and Medicaid Services) liability by guiding clients on the crucial differences between Medical Care and Medical Compliance. This consulting division is comprised of experienced, board-certified physicians who offer not only a valuable clinical perspective, but also the necessary expertise in medical compliance. Hospitals who engage these services receive complimentary chart reviews prior to full engagement of services. This approach provides potential clients with a clear view of revenue and liability situations at their facility. A competitive per-chart cost and invaluable legal expertise in the appeals process underscore the value of the service as part of a long term strategy for physicians and hospital administrators.

Many hospitals and health networks across the country are straining under the weight of high patient volume and reimbursement challenges. While quality healthcare may be provided on a consistent basis, the crucial decision of whether to hospitalize patients after initial review in the Emergency Room becomes an ongoing challenge. If, by CMS standards, this decision is made incorrectly, patients may be hospitalized under terms that will lead to liability for the hospital in question. If hospitals choose not to hospitalize patients that would benefit from additional care, then revenue and optimal patient outcomes are negatively impacted. It is within this complex decision-making area that the People’s Choice Hospital Revenue Enhancement services are invaluable.

In 2008, the role of determining the medical necessity of hospitalization and correction of potentially improper payments was given to the Medicare Administrative Contractors (MACs) and Recovery Audit Contractors (RACs). Since then, these teams have conducted case-by-case historical reviews of Inpatient hospitalizations with the goal of determining whether hospitalization was medically necessary. From this point forward, all hospitals seeking Medicare/Medicaid reimbursements were subject to reviews by these auditors. Despite the best efforts of medical professionals and hospital administrators, many hospitals are not consistently in compliance with the medically necessary stipulation of inpatient hospitalizations.

The most common diagnoses, which lead to what are deemed ‘unnecessary admissions,’ range from chest pain to congestive heart failure to acute renal failure. While these are clearly high-risk diagnoses that would imply the need for hospitalization, CMS projections have determined alternate approaches are needed to ensure patient well being without costly hospitalization. To make an informed decision on whether to hospitalize a patient, physicians must carefully weigh a standard set of variables:

• The medical history of the patient
• The present medical needs of the patient
• The options available for the patient in either the Inpatient or Ambulatory environment
• The established policies and procedures of a hospital

Detailed components of medical necessity must be considered by the physician in order to meet the necessary thresholds for hospitalization. It is within this challenging arena that the People’s Choice Hospital revenue enhancement division provides compelling solutions.

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