What can claims data tell the case manager?

Prof Case Manag. 2008 Jul-Aug;13(4):195-208; quiz 209-10. doi: 10.1097/01.PCAMA.0000327408.71354.52.


Purpose of study: This article seeks to use claims data to evaluate provision of service in 4 diagnosis-related groups (DRGs) for a rural hospital in an effort to better understand an increasing length of stay (LOS) and a decreasing case mix index (CMI). The complexity of the patient drives the services delivered, but does it drive the DRG assignment? Reimbursement for inpatient medical services is driven by DRG assignment and has an associated expected LOS. LOS is a result of the combination of physician practice patterns, available services, and the medical complexity of the patient. Itemized hospital charges can provide sufficient information to examine service delivery in broad categories. When compared to the services delivered through a professional protocol, physician practice benchmarks can be created. Identifying those services that are consistent and inconsistent with the protocol can prove illuminating and point to under- and overutilization, inadequate documentation, as well as opportunities for physician education.

Primary practice setting(s): Although this study was undertaken using hospital inpatient claims, the study can be recreated in almost any practice setting where there is a consistent mechanism to capture the provision of services. In the broader scheme, as case management practice transitions from functional models to outcome models, the relevance of these issues becomes more profound. The information gleaned from such a study can not only benefit case management administrators but inform and impact those involved in case management at any level. Indeed, the information can illuminate practice patterns for those beyond the case management sector and can include financial administrators, physician practice managers, and physicians.

Methodology and sample: A combination of developmental and casual-comparative methodology was applied to this study. The results of this study will create baselines for current practice patterns from which improvement opportunities in both resource and quality management can be identified. Casual-comparative research identifies a consequence and attempts to trace it back to its origin. In this case, the discharge diagnosis, a function of documentation, is the consequence, and this study attempts to determine whether physician practice patterns are accurately reflected in that documentation. The sample consisted of the itemized claims data for all patients discharged from Putnam Community Medical Center (PCMC) between January 1 and June 30, 2006, with a discharge DRG of 127, 089, 088, or 143. Records that did not have sufficient charges to map provision of care were excluded.

Conclusions: An analysis of the charges for the selected DRGs illustrates the actual care provided to the patient, rather than the resultant coding based on physician documentation. This finding leads to 1 of 3 conclusions: physician documentation is inadequate to allow accurate coding of services delivered; the physician may be ordering unnecessary services/interventions; or medical record coding may be suboptimal. The scope of today's acute care case management department often includes social work, utilization review, discharge planning, and resource management. Within that scope is the accountability for certain aspects of the hospital's financial performance, not the least of which is LOS. A clear understanding of the payer mix and the effect upon financial performance is necessary. Management of DRG reimbursement-based contracts requires investigation of practice patterns that may increase LOS, and documentation that can affect medical coding decisions. The results of these activities can guide clinical practice guideline adoption or development and identify opportunities to fine-tune documentation to better reflect services provided and support utilization decisions.

Implications for case management practice: Case Management Society of America (CMSA) Standards of Practice charge the profession with engaging strategies whenever possible to improve outcomes. Performance indicators include advocacy, resource management/stewardship, and research utilization. Addressing physician practice patterns and reducing nonessential services are examples of advocacy at the service-delivery level. These activities are also examples of resource management/stewardship as they seek to "promote the most effective and efficient use of healthcare services and financial resources" (CMSA, 2002, p. 19). The standards of practice call for research utilization and encourage research activities that are appropriate to case management practice and the subsequent sharing of those findings. In this way, the profession is enriched and promotes cost-effective, quality care and case management practice.

MeSH terms

  • Aged
  • Benchmarking*
  • Case Management*
  • Critical Pathways
  • Diagnosis-Related Groups / statistics & numerical data
  • Female
  • Guideline Adherence / statistics & numerical data*
  • Hospitals, Rural
  • Humans
  • Insurance Claim Review*
  • Length of Stay / statistics & numerical data
  • Male
  • Practice Patterns, Physicians' / statistics & numerical data*
  • United States