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
Primary Funding Source: Agency for Healthcare Research and Quality RO3 HS 10667-01.
Session #1181 - Health Systems
The 29th Annual MNRS Research Conference (April 1-4, 2005)