Picis launches LYNX CareBridge software to help hospitals address medical necessity challenges

To admit or not to admit? That’s the question being asked by many emergency department (ED) physicians and hospital administrators hundreds of times a day. Hospitals often place patients into observation who might otherwise be admitted, because intensity of service and medical necessity for these patients are not clearly defined or documented. Making wrong decisions could mean significant losses to hospitals that are already facing rising financial and regulatory pressures and struggling to stay afloat in this challenging healthcare economy. In response, Picis today launched LYNX CareBridge^®, the first software solution designed to help hospitals address this medical necessity challenge by providing accurate documentation to comply with Centers for Medicare and Medicaid Services (CMS) regulations. LYNX CareBridge also helps hospitals defend admissions decisions and remain audit-ready. Accurate and appropriate billing and documentation regarding medical necessity determinations have the potential to increase revenue for some hospitals by nearly $5 million per year per hospital.

“By providing more accurate documentation to defend admissions decisions, CareBridge has the potential to make an enormous impact on a hospital’s bottom line, which has never been more critical.”

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“The medical necessity issue that starts in the ED — the decision to either admit a patient from the emergency department (ED) into the hospital for specialized care or place them under observation in the ED — is one that every CFO should be examining very closely, as it could end up costing them millions of dollars, either in retroactive audits or in revenue they aren’t even aware they could be generating,” said Dr. Jim Fox, emergency physician at St. John Health System in Detroit, MI and member of the American College of Emergency Physicians (ACEP) reimbursement committee since 1995. “By providing more accurate documentation to defend admissions decisions, CareBridge has the potential to make an enormous impact on a hospital’s bottom line, which has never been more critical.”

Pressure On, Observations Up, Admissions Down

Approximately $993 million in improper Medicare payments were collected through Medicare’s Recovery Audit Contractor (RAC) program as of March 2008. Financial pressures on hospitals have never been greater, with programs like RAC going nationwide after collecting $33 million from hospitals in New York, California and Florida for the treatment of one condition alone (heart failure and shock) in the wrong setting and deemed medically unnecessary.

Under these increasing financial pressures, the medical necessity decision has become even more critical. Hospitals are reimbursed an average of $1,000 for the care of a patient put in observation status, while admission into another area or floor of the hospital — even less than a two-day inpatient stay — yields the hospital approximately $7,500. With most hospital EDs facilitating the treatment of nearly 30,000 to 150,000 patients a year, hospitals can lose millions by failing to address the medical necessity issue, without accurate coding and documentation to ensure they are reimbursed for the care they provide.

Better Admissions Decision-Making Today Keeps Auditors Away

Using CareBridge, a hospital ED can better support its admissions and observation rates. CareBridge is the first product to allow hospitals to configure specific hospital policies around determining appropriate admissions and observation practices and then capture medical necessity documentation to support the disposition decision and assignment of the appropriate level of care. This leads to defensible and accurate reimbursement for the care provided. CareBridge allows hospitals to:

• Customize to Hospital Needs: Hospitals can configure CareBridge to apply their specific policies for determining appropriate admissions and observation services by adjusting the weights associated with the CareBridge parameters.
• Capture Necessary Documentation: CareBridge captures detailed diagnoses, comprehensive medical risk factors, objective clinical data, present on admission (POA) conditions, patient safety factors and a physician’s plan of care.
• Analyze Results and Flag Concerns: Clinicians receive messages noting whether or not the documentation supports the admission or observation decision, and identifying any inconsistencies between recorded patient risk factors and the plan of care.
• Defend Decisions and Protect Revenue: A documented summary of medical necessity and physician intent is generated for use as the first line of defense in the event of payer audits, and is useful as a communication instrument for clinical hand-off.

“We designed CareBridge based on feedback from our customers who identified the admission vs. observation decision as a critical piece of their financial futures,” said Mike DeTolla, Senior Vice President, LYNX Medical Systems, a Picis Company. “With hospital executives today facing a range of challenges, we’re proud to be the first to deliver a solution that increases their bottom line by tackling this medical necessity issue head on at the point of care, so that they can continue to focus on investments that help improve the quality of patient care.”

Availability

LYNX CareBridge is immediately available for sale and implementation and more information is available on www.lynxmed.com. Picis is scheduled to demonstrate LYNX CareBridge at HIMSS 2010 Conference & Exhibition, March 1-5 in Atlanta, Georgia in Picis booth #941.

SOURCE Picis, Inc.