2.50
Hdl Handle:
http://hdl.handle.net/10755/159132
Type:
Presentation
Title:
Hospital Staff Responses to Denials of Reimbursement by Payers
Abstract:
Hospital Staff Responses to Denials of Reimbursement by Payers
Conference Sponsor:Midwest Nursing Research Society
Conference Year:2005
Author:Murray, Mary Ellen, PhD, RN
P.I. Institution Name:University of Wisconsin - Madison
Title:Associate Professor
Contact Address:School of Nursing, 600 Highland Avenue, Madison, WI, 53792, USA
Contact Telephone:608-263-6945
Co-Authors:Roberta Pawlak, MS, RN, Predoctoral Student; Judith Westphal, MSN, RN, Predoctoral Student; Julie Darmody, MSN, BSN, RN, Predoctoral Student; Yulia Semeniuk, MS, RN, Predoctoral Student; and Mary Hook, MS, RN, Predoctoral Student
Purpose: To examine the responses and attitudes of hospital staff members who receive a denial of certification for reimbursement when providing clinical information for third party payers. Conceptual Framework: The study was conducted within a health services research (HSR) cost containment framework. Design: A qualitative, concurrent design was used in which each staff member who received a denial of certification during the 12-month study period was asked to complete an audiotaped interview. Subjects: The hospital staff included nurse case managers (N=18), clinical social workers (N=9), assistive personnel (N=8), and additional registered nurses (N=2). Interviews with hospital staff were obtained for 99 of the 102 denials of reimbursement (97%) that occurred in the one-year study period. Method: The audiotaped interviews were transcribed, and analyzed using the affinity process. The analysis team consisted of 5 doctoral students in nursing and the principal investigator.
Results: Key themes that emerged from the data include: (1) Hospital staff refusal to accept responsibility for informing patient or family member of denial, (2) Protective responses of patient by hospital staff when denial occurs, (3) MD with limited or no involvement in the process, (4) Initiation of adversarial payer-provider relationship when the payer makes a denial, (5) Occasional recognition that the denial decision is correct and payer/provider cooperative relationship created, (6) Social issues related to denials, and (7) Feelings of powerlessness of hospital staff to affect physician and payer decisions. Conclusions: Participation in the process produces conflict in hospital employees who perform this function. These employees identify themselves as patient advocates in the opposition of payer pressures to reduce inpatient utilization. This study raises important questions about the responsibility of health care providers to discuss financial issues related to patient care and the potential conflict this causes within the patient/provider/payer relationship. Key words: cost, reimbursement, utilization
Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Midwest Nursing Research Society

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleHospital Staff Responses to Denials of Reimbursement by Payersen_GB
dc.identifier.urihttp://hdl.handle.net/10755/159132-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Hospital Staff Responses to Denials of Reimbursement by Payers</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Midwest Nursing Research Society</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2005</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Murray, Mary Ellen, PhD, RN</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">University of Wisconsin - Madison</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Associate Professor</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">School of Nursing, 600 Highland Avenue, Madison, WI, 53792, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">608-263-6945</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">memurra1@wisc.edu</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Roberta Pawlak, MS, RN, Predoctoral Student; Judith Westphal, MSN, RN, Predoctoral Student; Julie Darmody, MSN, BSN, RN, Predoctoral Student; Yulia Semeniuk, MS, RN, Predoctoral Student; and Mary Hook, MS, RN, Predoctoral Student</td></tr><tr><td colspan="2" class="item-abstract">Purpose: To examine the responses and attitudes of hospital staff members who receive a denial of certification for reimbursement when providing clinical information for third party payers. Conceptual Framework: The study was conducted within a health services research (HSR) cost containment framework. Design: A qualitative, concurrent design was used in which each staff member who received a denial of certification during the 12-month study period was asked to complete an audiotaped interview. Subjects: The hospital staff included nurse case managers (N=18), clinical social workers (N=9), assistive personnel (N=8), and additional registered nurses (N=2). Interviews with hospital staff were obtained for 99 of the 102 denials of reimbursement (97%) that occurred in the one-year study period. Method: The audiotaped interviews were transcribed, and analyzed using the affinity process. The analysis team consisted of 5 doctoral students in nursing and the principal investigator. <br/>Results: Key themes that emerged from the data include: (1) Hospital staff refusal to accept responsibility for informing patient or family member of denial, (2) Protective responses of patient by hospital staff when denial occurs, (3) MD with limited or no involvement in the process, (4) Initiation of adversarial payer-provider relationship when the payer makes a denial, (5) Occasional recognition that the denial decision is correct and payer/provider cooperative relationship created, (6) Social issues related to denials, and (7) Feelings of powerlessness of hospital staff to affect physician and payer decisions. Conclusions: Participation in the process produces conflict in hospital employees who perform this function. These employees identify themselves as patient advocates in the opposition of payer pressures to reduce inpatient utilization. This study raises important questions about the responsibility of health care providers to discuss financial issues related to patient care and the potential conflict this causes within the patient/provider/payer relationship. Key words: cost, reimbursement, utilization</td></tr></table>en_GB
dc.date.available2011-10-26T21:44:09Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T21:44:09Z-
dc.description.sponsorshipMidwest Nursing Research Societyen_GB
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