When a patient is admitted to the hospital, the most expensive days are the first few. These are the days when the patient is the sickest and the hospital staff is running tests and doing workups trying to sort out the patient’s condition. After that, the diagnostic intensity usually slows down. The hospital staff shifts to treatment mode and the patient starts to improve. Eventually the patient is discharged.

So when does it make sense for the patient to go home? When should the last day be denied or approved?

Just because a doctor is late making rounds or the patient hasn’t established a place to go isn’t a good reason for extending the hospital stay an extra day. On the other hand, the last day of a ten-day stay does not equate to 10 percent of the cost. It’s less than that because the big costs are encountered during the first few days of the patient’s stay. Thus, payers should understand that eliminating that last day won’t necessarily result in the cost reductions they are hoping for.

The last day of a hospital day becomes valid when patients:

Still require acute care services, such as IVs, medicines, antibiotics and pain medication

Are not yet eating and have not demonstrated bowel continuity

When, despite the best efforts of the hospital staff, the diagnosis of the patient is still in doubt

An IRO can help the payer determine the medical necessity of that last day by checking the patient’s condition against their medical record, and assessing whether or not acute care services still require a hospital or could better be applied elsewhere.

AllMed Healthcare Management Founded in 1995, AllMed (http://www.allmedmd.com, http://www.allmedmd.com/blog/index.htm) is a URAC-accredited Independent Review Organization (IRO) serving insurance payers, providers, TPAs and claims managers nationwide. Reviews are conducted by board-certified physicians in active practice. AllMed's growing customer base includes premier organizations, such as Educator's Mutual Life, IMS Managed Care, Tenet Healthcare Corporation, HealthGuard, several Blue Cross Blue Shield organizations, TriWest Healthcare Alliance, Allianz and many other leading healthcare payers.

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