Dependent patients prioritized in Greater Regional plan update

Patients waiting to be moved to a care-assisted home will have Greater Regional looking out for them. An update to Greater Regional Health’s utilization review plan was approved during this month’s regular board meeting on Monday, adding a new definition of patient care to be used for payment by insurance agencies which was previously unavailable.

Updating the UR plan became a point of discussion as the Greater Regional board of trustees sought to understand the process more.

Utilization review is the process the hospital performs on a daily basis by analyzing hospitalized patients for their level of care. This matters in applying for insurance by offering specific descriptions of the care a patient is receiving.

“It’s all about payment,” Chief Nursing Officer Amanda Mohr said. “It’s to make sure the patient gets what they need.”

A UR nurse will have an understanding of how insurance companies codify their claim policies and matches the care a patient is receiving to an insurance plan. It’s a major part of how hospitals assist patients in receiving their insurance claims.

The updated plan adds a new sixth definition of patient care which Greater Regional called custodial care. Patients who are admitted who do not require any medical necessities or acute care but would remain hospitalized. This can occur when the patient doesn’t have a place of residence or a facility to transfer to.

“We sometimes have patients, they have a hard time deciding what nursing home to go to, or they just don’t have somewhere to go,” Mohr said. “They don’t qualify under any of these levels of care. So, this gives them the option to still stay here and receive care.”

Fighting insurance agencies has been a major part of updating the UR plan. When insurance companies deny claims, the documentation and resources provided by UR can help revert those denials. In the past, Greater Regional has worked with UnityPoint for their UR services before hiring their own UR nurse to closely monitor these processes and fight an ever-changing insurance world.

Struggling against insurance agencies to give patients the care they need was a major reason for Chief of Staff Dr. Matthew Epp for making sure the UR plan was up-to-date, saying how insurance companies are “getting worse as time goes on.”

“The insurance world is very difficult,” Epp said. “From my perspective as a hospitalist... the Medicare advantage plans which are all the rave now on TV, a lot of people have transitioned to these care plans. They have further complexified the world of insurance for us and the hospital... They’ll entice people for premiums but they don’t pay as well, or there are challenges with how they structure the payments through primary insurance carriers. It makes it very tricky, a lot of gamesmanship is being done then to manage these things.”

Mohr gave an example situation where a patient is admitted to the hospital due to life-threatening complications with diabetes. If the patient receives the highest level of care possible at Greater Regional and released within 24 hours, insurance companies have an argument where, because the patient recovered within 24 hours, the care was only observational.

Chief Financial Officer Matt McCutchan expressed his frustration toward insurance companies with Medicare advantage plans. He noted how, even with an increased national Medicare advantage payer mix of 50%, Greater Regional is only at 11% of patients with advantage plans.

“We were able to keep those plans at bay for decades,” McCutchan said. “They’ve saturated the market with advertising... and by denying care, that’s their business model. I’ve seen some headlines where the government will reign in the advertising or reign in the denials, but I don’t know if it’s just lip service.”

In other hospital board news...

McCutchan gave the financial report for the month of February. Both revenue (6% over budget) and expenses (5% over budget) were higher than expected. An operating loss of 4%, or $300,000, was reported with a budgeted operating loss of 5%. Net income for the month was set at over $3.7 million.

Medicaid directed payment matching funds from the federal government was noted by McCutchan as potentially being “under attack” following recent changes to government spending. The hospital will receive their last payment for fiscal year 2025 in either May or June. McCutchan estimated the funds will most likely not leave for the next fiscal year but could not guarantee their presence beyond 2026.

Greater Regional approved matching the city of Creston’s contribution to the Southern Prairie Family Fitness Center of $60,000 as a part of their community reinvestment programs. The hospital noted the center’s contributions to the community in providing a location where physical exercise is encouraged for all ages.

Although not officially approved, the hospital plans to donate $120,000 to the center in the next two years. The board can’t guarantee payments over periods longer than one year, and will need additional approval in future meetings.

Two capital requisitions were approved. Chief Clinic Officer Carol Eckels requested the purchase of new clinic powered exam tables from vendor Medline. These powered beds were noted to be helpful for patients with mobility issues. Nine beds were requested at about $1,500 per bed.

Jackie Whitson requested the purchase of a surgical boom stand for lights and monitors. This equipment is used during surgeries. Whitson noted the last time one was purchased for the hospital was in 2011.

Chief Quality Officer Kim Weehler delivered the quality report for the month. Alongside updates to keep and update various certifications, Weehler said Greater Regional will be looking at expansions to their radiology department. In outlining areas of focus, cardiology and echocardiograms were mentioned. Greater Regional has already signed a new radiologist and is actively searching for another cardiologist.

A public hearing was set for 6:05 p.m. April 28 for a county budget amendment for fiscal year 2025. McCutchan noted Greater Regional has gone $4 million over budget, or 3%, and would need to this to be reported to the state. Clearing worries, McCutchan said this will not affect taxes and is simply a clerical necessity needed to receive further state funding.

Teresa Newman presented an award to Chief Human Resources Officer to Amy Rieck as the UnityPoint Outstanding Rural Leader. Rieck had originally received the reward in December during the 2024 UnityPoint Health Rural Leadership retreat.