Between you & me, ( and now the world!), Peds cases are hardly ever denied...some unwritten rule that we reviewers and Med Directors honor unless there is absolutely NO medical need found, after many days beyond the recommended length of stays.
What I do w/my "problem providers" is print out the criteria of the DX's that they are frequently admitting with that should have been OBS status, at max. Especially the "Chest Pain" and "Abd Pain" work ups.
I am very nice about it, telling them I don't expect them to know, remember all the criteria for every DX, blah blah blah, so here is something to help them when they do their initial H&P. I highlight the definitive criteria that is nec for meeting an IN admit status.
And I remind them that they can always change the admit status from IN to OBS during the H&P work up if the ER Doc wrote IN.
AND if they DO find something in their work up the first day, they can change any OBS to IN. Again, if nec.
When they have been given something concrete in their hands, it also alerts them that they are being watched closely and they take it seriously.
They take this approach more seriously than any talk of saving tax/insurance dollars; they really don't care about anybody else's money except their own.
But to imply they do not know the acuity level of patients hits their ego's!
This has been a very good method to get the drug seekers and frequent flyers out of the hospital in 23 hours.
By the way, If the patient came to the ER after 3PM, I approve almost all those stays a 48 hour OBS; but that's a personal thing with me.
Your Case Managers can always point this out to the Reviewers the next morning that are pushing to "Get 'em discharged today" for cases that are late in the day admits.
Personally, I do not think it is "fair" to penalize the facility by requiring them to do a 23 hour work-up in 13 hours for patients that present to the ER at 11PM; so I just ask my Medical Director to give 48 hour approvals for these cases that are not obviously drug seekers or frequent flyers. He concedes this w/me at least 95% of the time.
Hopefully, your facility won't suffer too badly w/the RAC Attacks, but if it does, please please please beg your Administrators to deal w/the Docs w/their admits in some type of LOSS-$haring plan, because that's the only way you'll Really get them to pay attention; when THEIR wallets are affected. They can make it part of their terms of admitting priviledges contract, that if their is a pattern of cases that should have been OBS that the hospital is being denied money for now; then the Admitting MD will share a percentage of the losses. The ER Docs should all be admitting (almost) everybody as OBS status except the absolutely worst case "made for ER TV" type of cases; and they can also share in a LO$$ percentage program.
There is no reason for the facility to have to eat the total loss of Income; they can only bill/submit claims based upon what the Docs ordered.
We have to keep our hospital's open; and RAC has the potential to close alot of doors; so the best we can do is make a more concerted effort to follow the InterQual &/or Milliman Criteria better NOW; because unfortunately; claims can't be re-submitted/changed after the patient is discharged.
I don't like that at all; way too harsh as far as I'm concerned. Personally, I think RAC was part of the last ditch efforts of the past administration to make it look like Medicare & Medicaid had alot more money available in the future and not as bankrupt as it is for the incoming regime. And it didn't matter which "party" won/loss this past election, it was simply started to make things appear better than they are; which now, unfortunately, is 100 times worse than we ever imagined.