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Emergency Department Gatekeepers –

Interventions with Chronic Pain Patients and Identity Fraud
By Sheryl L. Swan, RN, BSN, CCM

Emergency Department case managers can be gatekeepers for the recognition and management of interventions for complex patients. This
article outlines steps needed to establish gatekeeper programs highlighting focused interventions with both chronic pain patients and the
identity-fraud population seeking prescription drugs.
Chronic pain patients can present in a way that causes them to be flagged as potential “drug seeking” patients. It is important to develop
a program that validates and addresses chronic pain symptoms, putting these patients on a path of treatment that can minimize their use of
expensive ED level of care. An identity-fraud program provides mechanisms to identify possible drug-seeking behaviors without casting suspicion
on chronic pain patients. Positive outcomes from these programs include decreased length of stay, decreased organizational financial loss,
and improved community collaboration.

Both programs were developed using the same fundamental approach 3 Patient Advocacy – do patients receive personal attention that assures
to program development: assessment and data collection, staff education them the appropriate level of care and the assistance necessary to
and implementation, and evaluation and monitoring. These three steps navigate throughout the hospital system?
can be summarized as follows: 4 Outpatient Management – are patients matched appropriately
■ Data Collection and Assessment: to community-based services based upon their needs and
The ED patient population is reviewed to understand: financial capability?
1 Profile of patient demographics,
2 Dynamics of the census in the ED, such as peak utilization times Patients who experience chronic or recurring pain utilize ED services
and LOS, far more frequently than the rest of the population and thus become
3 Common barriers to receiving care, such as insurance, language, “high profile” patients. Not only do the condition(s) responsible for
functional and cognitive status, and accessibility of primary care, chronic pain demand treatment, these patients consume a number of
4 Common diagnoses and medical histories – chronic disease, different resources that are more expensive when sought through the ED:
psych/dual diagnoses, non-emergent complaints and staff time, prescription medications, and diagnostic resources. These
“frequent flyer” profiles. patients may also be at increased risk of being misidentified as “drug
seekers” if they are not successful in finding an alternative avenue for
These data are reviewed to identify those patient populations that
managing their chronic pain.
can be categorized as “high profile” because they create barriers to ED
Applying the three-step framework to the chronic pain patient
throughput, they consume unusually high amounts of resources, or they
population yielded a very successful program:
present a financial or compliance risk to the hospital.
■ Education and Implementation: ■ Data Collection and Assessment:
Staff members are educated to recognize the specific patient Chronic pain patients are assessed through a variety of methods. The
populations, to understand the goals of care plans developed specifically Utilization Review staff members monitor the daily ED patient list for
for these patients, and to understand the community resources available to recurring patients, ED physicians and staff members make referrals when
assist in their care. The implementation of specific programs includes: they have concerns about a patients’ non-compliance, and primary care
1 Development of population-specific care plans which are rooted in physicians or mental health providers now make referrals to the program.
evidence-based practice,
■ Education and Implementation:
2 Determine parameters of ED care to be provided,
Once a patient is identified, assessments are done of medical,
3 Identify community resources and programs available, functional, cognitive/emotional and social/environmental factors.
4 Establish and nurture collaborative relationships among hospital Information for the assessment is gathered from a variety of sources which
and community care providers. may include the patient, family, primary care physician, hospital records
reviews, and physical assessments while the patient is present in the ED.
■ Evaluation and Monitoring:
The assessments lead to a care plan which is developed in conjunction with
The goals of ED gatekeeper programs are cost-avoidance, assuring a primary care physician or other health provider (pain management clinic,
patient access to the appropriate level of care, and providing service to all mental health, etc.) whenever possible. The completed care plan is
ED patients. Data collected before and after program implementation to discussed with and given to the patient, a copy is placed in the medical
evaluate and monitor programs includes: ED visit volumes, outstanding record, and protocol is dictated into the computer medical record for
charges, and decreased utilization and non-reimbursed expenses per visit, immediate ED physician access.
which allows cost-avoidance projections. The outcomes that are measured
Care plans may include any number of the following instructions:
and evaluated are:
• Self-management and how to self-monitor
1 Quality of Care – are adverse occurrences and fragmentation
of care avoided? • Medication compliance
2 Fiscal Responsibility – are unnecessary admissions avoided? • Referral information - how to locate physicians and/or clinics

w w w . a c m a w e b . o r g

• Compliance with medical follow-up; how and when to contact the Misuse of this demographic information can take different forms but
primary care physician many patients will rely on a “similar variation” strategy. They simply alter a
• Identification of triggers that worsen the clinical condition and specific number in the real data or reproduce a similar pattern of numbers.
strategies for avoiding those triggers For instance, they may use the date of birth of other family members,
altering the year or month.
• Appropriate use of emergency care plan for emergencies
The ED case manager will work to confirm the altered demographic
The ED case manager reviews the care plan with the patient. information. This effort may include several approaches:
Recognizing that most patients will need repetition, the case manager
will often refer patients to classes or programs on pain management. 1 Determine the relationship with the rightful owner of the SSN and
The case manager will also arrange transportation, health clinic interview that owner if possible.
follow-ups, support group attendance and mental health referrals on 2 Interview the patient presenting to confirm a legal identification.
an as-needed basis for those with dual diagnoses that included a Document the fact if the patient refuses to present information or
psych component. acknowledges providing bad demographic information.
The chronic pain program allows some flexibility and creativity in
patient management. It is multi-disciplinary in nature and includes a focus 3 Use a claims management software tool for address verification. These
on education of the ED staff with a goal of changing perceptions about true tools provide SSN to address verifications.
chronic pain patients. They are not all “drug seekers.” Patients in the
program are periodically reassessed and their primary care physician or ■ Education and Implementation:
other healthcare providers are contacted for their assessments as well so Discussions with patients are focused on education so that they
that changing circumstances are integrated into the care plans. understand clearly that identity fraud is a crime, and if it is done in
order to obtain narcotic medications it becomes a felony. Presenting
■ Evaluation and Monitoring: patients under these circumstances are informed of the hospital’s
Cost avoidance studies can be performed to establish the effectiveness participation and cooperation with all appropriate authorities who
of the program. The ED visit histories of patients in the program can be include: local police department, Drug Enforcement Agency (DEA),
trended both before and after the care plan is implemented. (The total cost and the Social Security Administration.
avoidance for ED programs can be found in Exhibit A on page 8.) Once a potential identity fraud incident has been identified, the ED
case manager, working with hospital administration, will report the
IDENTITY FRAUD incident and details to the appropriate authorities. In some cases, this
Identity fraud in the ED is largely used by drug-seeking patients as may be post-visit and the patient may have already acquired the drug(s)
a way to “skate under the radar” of repeat visit screening – a screening and prescription(s) he or she was seeking.
tool used by many hospital EDs. It is a mechanism that allows for Specifically, the law enforcement and government agencies to contact
frequent visits not only to different EDs but to the same ED, creating a and the information to be provided are listed below:
new medical record and “trail” each time. Again, the three-step process
• Local Police Department – report the suspected “Prescription
provides the framework:
Under Fraudulent Information.” Most police departments will issue
a case number.
• Drug Enforcement Agency – the DEA will issue a regional pharmacy
Discussions with patients are alert for narcotic abuse or fraud in order to obtain narcotics so
that local pharmacies will watch for the name and other demographic
focused on education so that details provided by the patient should he or she attempt to fill
narcotic prescriptions.
they understand clearly that identity • Social Security Administration – report any fraudulent use of SSN
fraud is a crime, and if it is done or monies paid when social security number is used.
• Federal Trade Commission (FTC) – The FTC does not investigate
in order to obtain narcotic identity theft but they do facilitate reporting to a data clearinghouse
medications it becomes a felony. that is used by law enforcement agencies around the country
for investigations.

■ Evaluation and Monitoring:

The case manager maintains a tracking log of these incidents that
■ Assessment and Data Collection: includes information about the referral source, documentation of any
The initial assessment and identification of a possible fraudulent patterns of patient behavior, especially if multiple visits can be identified
patient is usually made by an admissions clerk or finance counselor who with different demographic details used, the agencies reported to and
discovers inconsistent information in the patient record. Most often, the any outstanding balances owed the hospital.
inconsistent information is an invalid match between date of birth, social Twenty-two cases were reviewed in 2005 and five individuals were
security number (SSN) and name. arrested during the actual act of fraud. Actual cost avoidance was $74,739,

(continued on page 8)

Emergency Department Gatekeepers – Interventions With Chronic Pain Patients and Identity Fraud (continued from page 7)

based on the outstanding charges related to the 22 cases. Of the five legal management gatekeeper programs are reported together. Therefore, the
cases pending, the facility will recover $43,448 for services rendered to these results include the two programs discussed in this article as well as an ED-
patients. Sentencing requests from the hospital always include a based program to assist the uninsured gain access to appropriate financing
recommendation that individuals obtain narcotic/drug counseling. mechanisms and health services and programs. In 2005, the total costs
avoided through these programs amounted to $250,000.
RESULTS The chronic pain and identity fraud programs are now being implemented
The financial results through cost-avoidance are summarized below in at all hospitals in the Denver area as a result of cooperation between ED case
aggregate. At Swedish Medical Center, the results of all the ED case managers. The commitment to insure the right care in the right setting for
chronic pain patients has led to a community-wide
Costs Avoided: Pre-Intervention Charges v. Post-Intervention Charges approach to consistently engaging these patients in care
plans that seek to reduce their reliance on ED care,
$450,000 regardless at which hospital they seek care.
$400,000 A consistent approach and cooperation between
hospitals in response to potential identity fraud has
created an environment that is aggressive in
$300,000 responding to this illegal behavior throughout the
metropolitan area. Again, increasing the likelihood
that patients will ultimately find appropriate
$200,000 treatment for any underlying addiction or other
$150,000 medical problems motivating the illegal behaviors.

$100,000 Sheryl L. Swan, RN, BSN is an ED case manager at

Swedish Medical Center in Englewood, CO. She
received her BSN from Midland Lutheran College,
$0 Fremont, NE and complete graduate coursework in
1999 2000 2001 2002 2003 2004 2005 Business Administration from Long Island University,
■ Actual Pre ■ Actual Post ■ Actual CA NY. She spent nine years working in several different
EXHIBIT A – This graph shows the comparison of charges incurred before intervention by the case nursing positions at U.S. Army medical facilities
management programs with the actual charges incurred post-intervention. Costs avoided (CA) including the Wm Keller Army Community Hospital,
include the difference between the two and the charges avoided when identity fraud is managed. United States Military Academy, West Point, NY.

The Evolution of Strategies to Increase Accuracy and Compliance in Level of Care Designation (continued from page 5)

and patient throughput. Leveraging case management expertise at Scripps Health has developed tools to measure these inaccuracies, which
registration is also expected to improve documentation of patient medical has allowed the health system to systematically test different strategies for
information and history that will aid in discharge planning. In addition, improvement. The result has been an evolution of strategies to correct
improved transfer screening is expected to reduce the acceptance of inaccuracies for level of care. Although the position of Admissions Case
inappropriate patient transfers. Manager and the Admission/Transfer Center are new, they are the results
of this systematic evolutionary process, and have been built on the
FUTURE IMPLEMENTATION foundation of past efforts and education. Based on the success of these
The measurement of success for the Admissions Case Manager and new roles, plans are underway to implement the Admissions/Transfer
the Admissions/Transfer Center will be registration accuracy for level of Center and/or the Admissions Case Manager position in all other Scripps
care, which will be assessed through ongoing retroactive reviews of 100 Health hospitals.
percent of Medicare admissions through the ED. Scripps Health has
Mary Elizabeth Whitehead, RN, BSN, MA, is the Administrative Director
established the expectation for this model to achieve accurate level of care
of System-Wide Case Management & Social Services at Scripps Health in
orders on 100 percent of patient records before discharge. Reaching this
San Diego, CA. She has held that position for over 8 years. She obtained her
goal will have the most direct effect on compliance and billing, because it
BSN from the University of Central Arkansas, School of Nursing and her
will ensure that all registrations are in compliance with CMS guidelines and
MA in Hospital Administration at Webster University in St. Louis, MO.
that all billing is accurate for level of care before the patient leaves the
She has 36 years of total nursing experience, with expertise in hospital
hospital. This can drastically decrease rework that must be performed in
administration and case management. She is a member of the Sigma
the billing department since bills can be sent out as they exist in the system
Theta Tau Organization and the ACMA.
when the patient is discharged, without requiring correction. An additional
metric of Saved Days, based on patient diagnosis, will be applied to Rose M. Turner, RN, BSN, ACM, has served in a Manager role in Case
measure success of the transfer screening function of this new model. Management at Scripps Health for the last 3 years. She obtained her BSN at
Scripps Health has found that the causes of inaccuracies in level of Texas Woman’s University and has a 26 years of nursing experience, 10 of
care orders are complex, requiring multiple solutions. More importantly, those in case management.