Post on 17-Dec-2015
transcript
RAC Risk Areas:Hospital Patient Status
Robert D. Stone, Esq.Alston & Bird LLP
Georgia Hospital Association
July 15, 2010
“In all we do, we must remember that the best health care decisions are made not by
government and insurance companies, but by patients and their doctors.”
George W. Bush, State of the Union Address
Increased Payor Scrutiny
“Hospitals, insurers battle over downcoding of patient stays” (The Intelligencer, July 6, 2010)– “Unashamedly, one of our efforts is to promote more
efficient care. No one is saying don’t be careful, don’t take the appropriate precautions. It’s about how do you appropriate pay for that resource, that amount of care that is being rendered.” Don Liss – Independence Blue Cross, Senior Medical Director.
Agenda
Physician’s role in determining patient status
Recent enforcement actions
Clinical risk areas related to patient status
Medicare rules and the use of Condition Code 44
The Case Management Assignment Protocol (CMAP) – History & current options
The Problem
Correctly assigning patient status to avoid:– Short Stay denials– False Claims allegations– Inappropriate use of “observation” services– Compromising SNF coverage – Condition Code 44 “Trap”
Medical Necessity: The Treating Physician’s Primary Role
The patient’s treating physician is responsible for determining whether a Medicare beneficiary needs to be admitted to a hospital.
“The physician or other practitioner responsible for a patient’s care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient.” MBPM Ch. 1 § 10.
Only A Doctor Can Legally Admit Patients to Hospitals
Generally, under state law, only physicians can order the inpatient admission of a patient. Nurses (including care managers) are not legally qualified to make that decision, which is outside their “scope of practice.” See, e.g., Georgia Medicaid Hosp. Manual § 901.1 (req. admissions by “licensed doctors”); 42 CFR 482.12(c)(2) (“Patients are admitted to the hospital only on a recommendation of a licensed practitioner permitted by the State to admit patients to a hospital.”)
“In no case may a non-physician make a final determination that a patient’s stay is not medically necessary or appropriate.” See Page 217 of the Medicare State Operations Manual, accessible at http://www.cms.hhs.gov/manuals/Downloads/som107.ap_a_hospitals.pdf.
Physician’s Judgment
By Medicare policy, the physician should consider the following factors in making a determination whether to admit a patient:
– The severity of the signs and symptoms exhibited by the patient;
– The medical predictability of something adverse happening to the patient;
– The need for diagnostic studies; and
– The availability of diagnostic procedures at the time.
Id.
“Complex Medical Judgment” Standard
“The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient’s medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital’s bylaws and admissions policies, and the relative appropriateness of treatment in each setting.” MBPM Ch. 1 § 10.
“Physician’s Expectation” Test
A patient should be considered an inpatient if the patient was admitted based on the physician’s expectation that an inpatient stay is appropriate. LMRP for Acute Care: Inpatient, Observation and Treatment Room Services (L1281) at 4 (January 1, 2005)
“Generally, a patient is considered an inpatient if formally admitted [by a doctor] as an inpatient with the expectation that he or she will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight.” MBPM Ch. 1 § 10
24-hour Benchmark
While Medicare guidance suggests physicians use a 24-hour benchmark for acute hospital services as a guide, “[a]dmissions of particular patients are not covered or non-covered solely on the basis of the length of time the patient actually spends in the hospital.” MBPM Ch. 1. § 10.
What happens after the decision to admit a patient is made by the treating physician can only be used to substantiate, not refute, the validity of the physician’s decision-making. BCBS LMRP at 5.
Common Published Criteria, Like InterQual, Recognize That A Physician’s Clinical Judgment Governs
“The Criteria reflect clinical interpretations and analyses and cannot alone either resolve medical ambiguities of particular situations or provide the sole basis for definitive decisions. The Criteria are intended solely for use as screening guidelines with respect to the medical appropriateness of healthcare services and not for final clinical or payment determinations concerning the type or level of medical care provided, or proposed to be provided, to a patient.” InterQual, Acute Criteria Review Process, RP-14 (2005).
Multiple Choice: Reimbursement Issue That Has Been Around For More Than A Decade Means:
A. The rules aren’t very clear
B. There are a lot of judgment calls where reasonable minds can differ
C. The “decider” and the “biller” aren’t the same
D. The problem often happens late at night, on weekends, holidays or in an “emergency”
E. All of the above
Multiple Choice: Reimbursement Issue That Has Been Around For More Than A Decade Means:
A. The rules aren’t very clear
B. There are a lot of judgment calls where reasonable minds can differ
C. The “decider” and the “biller” aren’t the same
D. The problem often happens late at night, on weekends, holidays or in an “emergency”
E. All of the above
A Short History Of “Short-stay” Enforcement
Issue in OIG Work Plans for at least 10 years
Saint Barnabas Case (2005): False Claims Act utilized in patient status case
Saint Joseph’s Health System (2007): Qui Tam action brought by a former case manager– Areas of Focus
• 1-day stays• “zero-day” stays• 3-day inpatient stay with discharge to SNF• 2 and 3-day inpatient stay where reimbursement > billed
charges• ESRD cases where patient missed dialysis due to blocked
access sites
Government Enforcement and Short-Stay Admissions: US ex rel. Ramsey v. Saint Joseph’s
Qui Tam action brought by former case manager who was employed only for a few months
Relator’s complaint based largely on anecdotal case stories
Case ultimately based upon large statistical analyses
Case evidences areas of particular risk
Other Enforcement Cases
Khyphoplasty Cases: Medtronic Spine (2008), HealthEast Care System (2009)
Yale-New Haven: procedure-related admissions (2009)
Wheaton Community Hospital (2010): medically unnecessary admissions
RAC Program
QIO Initiatives
Areas of Risk
Chest Pain and Cardiac DRGs
Payments Exceeding Charges
SNF Discharges
ER Point of Entry Cases
Cases related to patients presenting after outpatient tests or procedures
Dialysis
The False Claims Act and Short-Stay Admissions
“Knowledge” Factors– Hospital Audits (or lack thereof) and Work
Plan/Corrective Action– Education of Medical Staff and Case Management
Staff– PEPPER Reports– Administration Response to Feedback from Case
Management– Administrative Reports and Internal Data (Average
Length of Stay, for example)
Auditing Patient Status Issues
Inpatient Admission Coverage Criteria
Observation Services Coverage Criteria
Condition Code 44
Hospital UR Condition of Participation
Causes of Patient Status Errors
Differences of opinion (medical necessity)
Medical record documentation issues– Unclear orders– Unclear supporting documentation– Timing of orders/authentication/
implementation
Medicare Rules (very simplified)
Admission Following Observation– Effective at time of the admitting order
After Inpatient Admission– Unless Condition Code 44
• No APC billing, even if Admission is denied– “Part B only” services
CMS Physician Order Interpretations
“Admit” = Inpatient
“Admit as inpatient” = Inpatient
“Admit for observation” = Inpatient
“Admit to observation” = Outpatient
“Place in observation” = Outpatient
“Admit to Case Management Protocol” = None
“Condition Code 44” Criteria
Admission does not meet inpatient criteria
By 1 UR Committee member and the attending physician
Decision documented in medical record
Changed before discharge and any billing
Condition Code 44 – CMS Views
No substitute for utilization management staffing or continued medical staff education
“[T]he need for hospitals to correct inappropriate admissions and to report condition code 44 should become increasingly rare.”
42 C.F.R. § 482.30/Utilization Review Committee
Defines the process for hospital determination that an “admission . . . is not medically necessary.”
Consultation with treating physician or opportunity for treating physician to be heard is required
Physician members of UR Committee have power to change status
3 Notifications Required when patient status changes
Condition Code 44 distinguished
Case Management Assignment Protocols
“Florida Protocol”
Case Management Assignment Protocol (CMAP)– Standardized decision making process – Individual or standing orders to UR personnel– Assign status using recognized criteria
Case Management Assignment Protocol
Physician determines need for hospital care– Orders: “Admit to CMAP”– “Hold” status (e.g., 2, 6, 12 hours)– Default to Outpatient (Observation)
• If assigned Observation, physician re-evaluates within 24-48 hours for inpatient admission or discharge
Simplified CMAP Flow Diagram
Physician Orders “Admit to Case Management Protocol”
Case Management Assigns Status
Admitting Status Hold Physician Re-evaluates
Discharge Inpatient Service
Outpatient /Observation Service
Summary of CMAP Demonstration Project
Involved 16 hospitals in six western states
Only 35% of the records reviewed at the end of the project had evidence of use of the CMAP – but still showed measurable results overall
Variability in implementation of the protocol
Percentage of unnecessary short stays admissions decreased from 26.4% to 12.4%
Overall, the rate of short stays remained the same or increased for most hospitals
Lessons Learned from the CMAP Demonstration Project
Use of CMAP resulted in reduction in denial rates but NOT in short stays.– Shift from longer IP admission to observation status + short stay.– More accurate– Less expensive for CMS– Focus on decrease in denial rates not decrease in short stays
Possible nurse staffing issues with observation units
Training in use of protocol
Need to identify missed billing opportunities, particularly in the ED (may require additional training)
Need for a physician champion
Lessons Learned, cont’d.
Mandatory versus optional
Case management staffing issues– Improved accuracy on front-end may reduce costs involved in
appealing denials
Indirect benefits from use (or even attempted use) of protocol– Increased communication– Increased feedback– Increased sensitivity to patient status issues– Opportunities for education related to status issues– After initial resistance, physicians relieved to have case managers
with expertise available– Suggests opportunities for improvement exist, even without full
implementation of CMAP
Apparent CMS Concerns about CMAP
“Removes physician from the process”– The physician . . . responsible for a patient's care at the
hospital is also responsible for deciding whether the patient should be admitted as an inpatient
– But does it really?• Patient’s physician determined need for hospital• Medical staff physicians selected criteria
Apparent CMS Concerns about CMAP
“Defaulting to observation” (i.e., outpatient)– “General standing orders for observation services
following all outpatient surgery are not recognized.”
Long-standing distrust of “standing orders”– But see Memo to State Survey Agency Directors re:
“Standing Orders” in Hospitals (Oct. 24, 2008)
Why Isn’t Everyone Using CMAP?
NOT yet CMS approved
CMS position re “Admit to CMAP” orders – Standing or patient-specific– Supports neither Inpatient Admission nor Outpatient
Observation
MACs cannot approve proposed CMAPs
Modified Case Management Approach
No standing orders
No default to Outpatient/Observation
Case management reviews/recommends
Provides recommendation to physician
Requires separate order accepting the recommendation after it is made– Written signoff or properly noted telephone order should
be sufficient
Problems With Modified Approach
Additional Expense
Physician hassle factor– Having to sign twice
Delay – – Time before the second order does not count
• 8 hour minimum for Observation• 3 day Inpatient stay for SNF coverage
Current CMAP Conclusions
Sooner or later RACs will audit
CMAP actually works
Nevertheless, not CMS approved
Reliance on CMAP could lead to 100% denials– No orders for services
Modified CMAP approach may help
Saint Joseph’s Response: Systems Improvement
Proactive Response to Strengthen Case Management– Training– Mandatory Credentialing– Independent Review of Performance
Addition of Physician Advisor
Strengthening of UR Committee Function and Performance
Administration Support
Compliance Program Involvement
Saint Joseph’s Response: A Unique CIA
HHS-OIG approves use of “Admit to Case Management Protocol” as part of CIA
First case authorizing protocol by CIA
Outside of 6-state pilot
Allows Case Management Involvement with Physician at Front End of Process
Physician must still order status
Status held until consultation