Ralph Wuebker

Report
2015 Inpatient Prospective Payment Services (IPPS) and
Insights on Best Practices
Ralph Wuebker, MD, MBA
Chief Medical Officer
Executive Health Resources
©2014 Executive Health Resources, Inc. All rights reserved.
Agenda
•
2014/2015 IPPS Final Rule
•
2015 proposed OPPS
•
Transmittal 534/540/541
•
Appeals Settlement offer
•
Rebilling
•
Understand best practices for operating under 2015 IPPS
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2
Final IPPS 2015
AKA CMS 1607-F (Published in Federal Register on August 22, 2014)
1. Calculation of payments. The rule includes a 2.9 percent market basket update, offset by a negative 0.5 percent
productivity adjustment and a negative 0.2 percent market basket cut as mandated by the Patient Protection and
Affordable Care Act, and a negative 0.8 percent decrease in accordance with the American Taxpayer Relief Act of
2012.
2. Hospital readmission reduction program. CMS has increased the maximum penalty from 2 percent to 3 percent.
3. Hospital-acquired condition reduction program. Hospitals in the lowest quartile, will have their Medicare pay
decreased by 1 percent.
4. Price transparency. Under the final rule, hospitals are required to make public a list of their standard charges or
provide their policies for allowing the public to view a list of those charges in response to an inquiry.
5. Hospital value-based purchasing program. For 2015, CMS is increasing the applicable percent reduction, the
portion of Medicare payments available to fund the value-based incentive payments under the program, to 1.5
percent of Medicare reimbursements, resulting in about $1.4 billion in value-based incentives.
6. Medicare disproportionate share hospitals payments. As part of the PPACA, Medicare DSH payments will be
reduced 75 percent by 2019, or $49.9 billion. The final rule cuts overall Medicare DSH payments by 1.3 percent in
fiscal year 2015, compared with fiscal year 2014.
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3
Final IPPS 2015
Two Midnight rule remains intact
•
Little to no changes
•
Pages 50146 – 50148 pertain to the 2 midnight rule
•
Several comments regarding defining short or low cost inpatient hospital stays
•
No additional clinical exceptions added. However, still taking feedback: email to:
[email protected]
•
Although the FY 2015 IPPS/LTCH PPS proposed rule did not include any proposed regulatory
changes relating to the 2-midnight benchmark, we nonetheless received a number of public
comments regarding the current regulation.
•
CAH: finalize a policy that a CAH is required to complete all physician certification requirements
no later than 1 day before the date on which the claim for the inpatient service is submitted (pg.
50165)
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4
2015 Proposed OPPS
CMS 1613-P
The 2015 Outpatient Prospective Payment System (OPPS)
Proposed Rule was released on July 13, 2014
Comments found on www.regulations.gov
Highlights include:
• Refinements to Comprehensive APC Policy
• Significant Packaging of Ancillary Services
• Changes to Inpatient Certification Requirements
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5
The Proposed Rule and Elements
of Certification
Documentation is Key:
•
There is an expectation that the elements of certification (i.e. the reason for
hospitalization, the estimated time the patient will need to remain in the hospital, and
the plan of post-hospital care), generally can be satisfied by elements routinely found
in a patient’s medical record, such as progress notes (CMS-1613-P at 41057).
•
“[I]n most cases, the admission order, medical record, and progress notes will contain
sufficient information to support the medical necessity of an inpatient admission
without a separate requirement of an additional, formal, physician certification” (CMS1613-P at 41057).
•
“[W]e believe that evidence of additional review and documentation by a treating
physician beyond the admission order is necessary to substantiate the continued
medical necessity of long or costly inpatient stays” (CMS-1613-P at 41057).
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Proposed Changes to Physician
Certification Requirements
•
A separately signed Physician Certification statement would no longer be
required to be submitted with each and every Inpatient Hospital claim.
– Only required for long-stay (20 days or more) and outlier cases
•
The Inpatient Admission Order will continue to be required as a condition of
payment, but is no longer considered an element of certification.
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Proposed Changes to Physician
Certification Requirements
REMINDER, the 2015 OPPS Proposed Rules if finalized as written, would not
take effect, until the implementation date of January 1, 2015.
Until that time, providers should continue to adhere to current guidelines and
regulations pertaining to the Two-Midnight Rule and Physician Certification
Requirements
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8
“Doc Fix” – HR 4302
Extension of the Probe & Educate
CMS has extended the Inpatient Hospital Prepayment Review “Probe &
Educate” review process through March 2015. This means that:
•
Medicare Administrative Contractors (MACs) will continue to select claims for review and deny
claims found not in compliance with CMS-1599-F (commonly known as the “2-Midnight Rule”).
•
MACs will continue to hold educational sessions with hospitals as described below in “Selecting
Hospitals for Review” through March, 2015.
•
Generally, Recovery Auditors will not conduct post-payment patient status reviews of inpatient
hospital claims with dates of admission on or after October 1, 2013 through March 2015.
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Probe & Educate Process
Number of claims in sample that did NOT comply with policy
(Dates of admission October–March 2014)
No or minor concern
Moderate to significant
concerns
Major concerns
10 Claim
Sample
0–1
2–6
7 or more
25 Claim
Sample
0–2
3–13
14 or more
• Deny non-compliant
claims
• Send results letters
explaining each denial
• No more reviews will be
conducted under Probe &
Educate Process
• Deny non-compliant claims
• Send results letters
explaining each denial
• Offer 1:1 Phone Call
• REPEAT Probe & Educate
process with 10 or 25
claims
• Deny non-compliant claims
Action
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• Send results letters
explaining each denial
• Offer 1:1 Phone Call
• Repeat Probe & Educate
• If problems continue,
repeat P&E with increased
claim volume of 100–250.
10
Probe & Educate Status Update
As of February 7, 2014:
# of medical records
requested
# of medical records
received
# of medical records with
MAC reviews completed
29,158
18,110
6,012
As of February 24, 2014:
• CMS is requesting that the Medicare Administrative Contractors (MACs)
re-review all claim denials under the Probe & Educate process to ensure the claim
decision and subsequent education is consistent with the most recent clarifications.
Number of denials: ?????
Published data – NGS 30–75% denied
Source: http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/MedicalReview/Downloads/UpdateOnProbeEducateProcessForPosting02242014.pdf
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Examples
•
Example 3 - Short stays for medical conditions: The beneficiary
presented to the ED with recent onset of dizziness and denied any
additional complaints. The beneficiary reported a recent adjustment to his
blood pressure medication. The physician’s notes stated that the beneficiary
was stable and that his blood pressure medication was to be held and
dosage adjusted. The notes also indicated that the physician intended to
observe the beneficiary overnight. The beneficiary was discharged the next
day. The hospital submitted a claim for a
1-day inpatient stay. Upon review of the claim, the MAC denied Medicare
Part A payment because the medical record failed to support an expectation
of a
2-midnight stay.
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12
Examples
•
Example 4 - Physician attestation statements without supporting medical
record documentation: The physician’s order contained a checkbox with pre-printed
text stating “The beneficiary is expected to require 2 or more midnights of hospital
care.” The physician’s plan of care, however, stated that the beneficiary was to have
diagnostics performed post-operatively, with a plan to discharge in the morning if
stable. The beneficiary was discharged the following day as planned, after a 1midnight stay. Upon review of the claim, the MAC denied Medicare Part A payment
because the medical record failed to support an expectation of a 2-midnight stay
when the order was written.
•
CMS reminds providers that attestation statements indicating the beneficiary’s
hospital stay is “expected to span 2 or more midnights” are not required under
the inpatient admissions policy, nor are they adequate by themselves to
support the expectation of a 2-midnight stay. Rather, the expectation must be
supported by the entirety of the medical record.
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13
Transmittal 541, CR 8802
•
Earlier versions of Transmittal 541 have previously been introduced as Transmittals 505, 534
and 540; however those versions were rescinded.
•
Issued on September 12, 2014, but Implemented and Effective on September 8, 2014 (date of
service)
•
Provided the MAC, Recovery Auditor, and ZPIC the discretion to deny other related claims
submitted before or after the claim in question.
•
The Recovery Auditors will be allowed to also auto deny if approved by the New Issues Review
Board.
•
CHANGE FROM Transmittal 534 - Allowed as one approved example: now only a surgeon’s
claim could be automatically denied, but NOT recoded to an appropriate outpatient evaluation
and management service following the denial of a hospital’s inpatient admission.
•
CHANGE FROM Transmittal 540 – Paragraph in Policy section was changed to be consistent
with paragraph in Manual, with respect to the surgeon’s claim as outlined above.
Source: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2014-Transmittals-Items/R541PI.html
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14
The CMS Administrative
Agreement
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Appeals Backlog
•
•
•
•
•
•
•
The average processing time for appeals decided in fiscal year 2014 is 398.1 days.
For comparison, the average processing time for a case in 2009 was 94.9 days.
There are currently 480,000 appeals awaiting assignment to an ALJ
In early 2014, OMHA received 15,000 appeal requests per week, up from 1250 appeals per week
2 years ago.
OMHA received a total of 320,000 claims in FY 2012, and over 600,000 claims in FY 2013.
OMHA is currently anticipating the backlog to grow to 1,000,000 appeals by end of FY 2014.
OMHA projects that its FY 2015 caseload will increase to approximately 850,000 total claims.
Processing backlogs
•
15 weeks from receipt to open mail (though mail is stamped received as of the date it was
physically received, not the date it is opened)
•
20-24 weeks from the date mail is received until it is entered into OMHA’s database (this is the
point at which the case becomes searchable in response to inquiries)
•
Up to 28 months from receipt until case is assigned to a judge
•
6 months for a hearing date after a case is assigned to a judge
Source: http://www.hhs.gov/omha/important_notice_regarding_adjudication_timeframes.html
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OMHA Statistical Sampling
In July, 2014, OMHA announced pilot programs to address the high-volume backlog at the
Administrative Law Judge level of appeal.
What is OMHA Statistical Sampling?:
•
A statistical expert develops an appropriate sampling methodology in
accordance with Medicare guidelines
•
Sample units are then randomly selected from a universe of claims based on
that methodology
•
An Administrative Law Judge then reviews the sample units and makes
findings and a decision on those sample units in a single appeal
•
The results of the sample are then extrapolated to the entire universe
Source: http://www.hhs.gov/omha/statistical_sampling_initiative.html (last visited September 10, 2014)
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OMHA Statistical Sampling
To be eligible for OMHA statistical sampling:
•
•
•
•
•
•
A request for hearing must appeal a Medicare Qualified Independent Contractor
(QIC) reconsideration decision.
The appellant must be a single Medicare provider or supplier.
All jurisdictional requirements for a hearing before an Administrative Law Judge
must be met for the request for hearing and all appealed claims.
The claims must be currently assigned to one or more Administrative Law Judges
or have been filed during the time period currently being assigned by OMHA
Central Operations – at this time, that includes appeals that were filed between
April 1, 2013, and June 30, 2013.
No hearing on the claim has been scheduled or conducted.
There must be a minimum of 250 claims and all claims must fall into only one of
the following categories:
– Pre-payment claim denials;
– Post-payment (overpayment) non-Recovery Audit Contractor (RAC) claim
denials; or
– Post-payment (overpayment) RAC claim denials from one RAC.
Source: http://www.hhs.gov/omha/statistical_sampling_initiative.html (last visited September 10, 2014)
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18
Administrative Agreement
• CMS is offering an Administrative Agreement
(Settlement) to:
– Any acute care hospital
• Those paid via Prospective Payment System (PPS), Periodic
Interim Payments (PIP), and Maryland waiver
– Critical access hospital (CAH)
– Willing to resolve their pending appeals (or waive their
right to request an appeal)
– In exchange for timely partial payment (68% of the net
payable amount).
Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/MedicalReview/InpatientHospitalReviews.html
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Eligible Claims
Claims meeting all of the criteria are eligible and
ALL eligible claims must be included in the request
for Administrative Agreement.
Cannot Pick & Choose Claims
Eligible claims must be included in a spreadsheet
that the hospital is required to complete and
submitted along with the Administrative Agreement
request.
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20
Eligible Claims (con’t)
•
The claim was denied by any entity that conducted a review on behalf of CMS;
•
The claim was not for items or services furnished to a Medicare Part C enrollee;
•
The claim was denied based upon a Patient Status Determination - The claim was
denied based on an inappropriate setting determination, that is, on the basis that the
service might have been reasonable and necessary, but treatment on an inpatient
basis was not;
•
The first day of the admission was before October 1, 2013;
•
The Hospital timely appealed the denial;
•
As of the date of an executed Agreement submitted to CMS by the Hospital:
– The appeal decision was still pending at the MAC, QIC, ALJ, or DAB levels of
review, or
– The Hospital had not yet exhausted its appeal rights at the MAC, QIC, ALJ, or
DAB level; and
•
The Hospital did not receive payment for the service as a Part B claim (re-bill).
Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html
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Payment by CMS
CMS agrees to pay the Hospital sixty-eight (68) percent (‘the percentage”) of the net
paid amount of each denied inpatient claim.
•
“Net paid amount” means the payment on the original inpatient claim net paid
amount;
–
Net Paid amount excludes the out-of-pocket obligations that are included in the “gross” or “allowable”
amounts.
•
This payment will be made in one payment per hospital provider number, or per
owner or operator of multiple settling hospitals.
•
CMS will refund to the Hospital all interest on any claim included in any appeal
covered by the Agreement that CMS has collected from the Hospital as of the
effective date of the Agreement
–
–
If CMS fails to make payment within the allotted sixty (60) days, CMS will pay interest to the Hospital
for the period beginning on day sixty-one (61) through the date of payment.
The interest rate shall be the Current Value of Funds Rate (“CVFR”) as promulgated by the United
States Department of the Treasury.
Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/MedicalReview/Downloads/External-FAQs8-cleared-909-v2_508.pdf
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22
Miscellaneous Provisions
•
If the Hospital has not fully repaid the originally denied amount on a claim
included in an appeal listed on the spreadsheet of eligible claims, the
Hospital will receive for that claim payment the percentage value applied
less the outstanding overpayment balance.
•
If the Hospital has not yet repaid any of the originally denied amounts on a
claim included in an appeal, or where the amount retained by the Hospital
exceeds sixty-eight (68) percent of the net paid amount, the Hospital will
owe CMS a refund for that claim.
– CMS will calculate the refund amount as the difference between the retained amount
and sixty-eight (68) percent of the net paid amount.
– Any refund owed CMS will be subtracted from the total payment due under this
Agreement or from future Medicare payments to the Hospital.
Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/MedicalReview/Downloads/AdminstrativeAgreement.pdf
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Miscellaneous Provisions
• The Hospital agrees it will not commence any further appeals or
actions of any kind challenging the Medicare contractor’s
determination(s) regarding the claims included in the appeals
– The Hospital will not attempt to rebill any of those services under Part B.
• CMS retains the right to recoup any duplicate or incorrect payments
made for claims that were, but should not have been, included under
this Agreement
– Payments that may have been made in the appeals process or secondary to Part
B billing inadvertently included among the payment made under this Agreement.
• The Agreement does not include a release of liability of any claims
the United States may have under the False Claims Act, (31 U.S.C.
section 3729 et seq.), the Civil Monetary Penalties Law, (42 U.S.C.
section 1320a-7a), or the common law theories of payment by
mistake, unjust enrichment, or fraud.
Source:http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/MedicalReview/Downloads/AdminstrativeAgreement.pdf
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24
CMS Settlement Process
Basic Settlement Process:
• Decision must be made and process started Oct 31, 2014
• Provider submits eligible claims spreadsheet
• CMS reviews and provides feedback allowing provider time to
abandon/proceed with settlement
• Medicare signs initial Administrative Agreement and pays
provider for those claims agreed upon
• A repeat of the process occurs with respect to any
discrepancies concerning the eligibility of claims
• CMS employs a final reconciliation process and makes
additional adjustments as warranted
• Continue to check the CMS website for updates…
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25
Patient Deductible Responsibilities
The providers refund responsibility is as follows:
a.
If the Beneficiary co-insurance has been collected at the time the INITIAL
administrative agreement is signed by the provider, no refund is required.
b.
If the Beneficiary co-insurance has not been collected at the time the
INITIAL Administrative Agreement is signed by the provider, the provider
must cease collections.
c.
If a Beneficiary repayment plan has been executed at the time the
INITIAL Administrative Agreement is signed by the provider, the
provider may continue to collect the co-insurance in accordance with the
repayment plan.
Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/MedicalReview/Downloads/External-FAQs8-cleared-909-v2_508.pdf
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26
Key Considerations
•
•
•
•
•
•
•
•
Every Hospital Should be Asking These Questions…
Is my hospital an eligible facility?
How do I determine which claims are eligible?
How many eligible claims do I have?
What is the total value of the eligible claims?
What is the value of those claims if I rebill under Part B?
What is the administrative burden to engage in the
settlement?
How long have my appeals been in the appeals process?
What has been my appeals success rate?
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27
Key Considerations
Every Hospital Should be Asking These Questions…
• What is my hospital’s financial situation with respect to the
settlement?
• How much reserve did we assign to denied claims (i.e.,
was it more or less than 68%)?
• What is the impact of denied days on the calculation of
GME, IME, and DSH payments?
• What percent, if any, of the patient deductible has been
paid?
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28
Finally
• No right answer for every hospital
• Every hospital should evaluate the offer
• Expect some facilities will accept the offer
and others will reject the offer
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29
Rebilling
•
If a case has a physician inpatient order, yet fails “expectation 2 midnight
stay” or medical necessity:
– If patient is still in the hospital, hospital may use Condition Code 44 to
reclassify patient as in the past
– If patient has been discharged, hospital may use Self Audit/Rebilling if
within timely filing requirements
•
Rebilling:
– Submit provider-liable Part A claim
– Summit an inpatient claim for payment under Part B and outpatient
claim for Part B appropriate services
– Status does not change – remains IP
– Beneficiary responsible for Part B copayments
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30
Rebilling Evolution
Prior to new rulings
Interim 1455
CMS final rule
Self-auditing
Bill Part B Ancillaries only.
Subject to limitations of
CC 44
Allows providers to rebill only
for claims denied by a
Medicare contractor
Allows providers to rebill
inpatient Part A claims denied as
a result of a “self-audit”
Part B rebilling
Only allowed if Judge
determined appropriate.
No regulations
Rebilling of covered Part B charges
when the Part A claim
is denied as not medically
reasonable and necessary
Part B rebilling to claims for
services rendered to
beneficiaries enrolled in
Medicare Part B
Timeliness for
rebilling
Only if within timely filing (one
year) or Judge orders (no time
limit)
Allows for rebilling 180 days from
denial or lost appeal
with date of service before
Sept. 30, 2013
Standard timely filing
requirements (1 year from the
date of service) on rebilled claims
with an admission date after
October 1, 2013.
Impact to
beneficiary
To be held harmless
Upon rebilling, requires hospital
to adjust beneficiary billing
Upon rebilling, requires hospital
to adjust beneficiary billing
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31
Does Rebilling Make Cents?
• Where are you most likely to miss revenue in the UR process?
• Without concurrent reviews hospitals risk losing dollars on
observation/outpatient cases!
• Consider:
INPT DRG
> CC44 with 8 hours obs (APC)
> CC 44 with less than 8 hours of obs (No APC)
> Post discharge rebill 12x
> Claimed denied after 1 year
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32
Best Practices to Comply with
Current IPPS
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Conditions of Participations Have
Not Changed
Conditions of Participations (CoPs) must be followed
•
“We did not propose and are not finalizing a policy that would allow
hospitals to bill Part B following an inpatient reasonable and necessary selfaudit determination that does not conform to the requirements for utilization
review under the CoPs.”
– Page 50913, 2014 IPPS
•
482.30 (c)(1) The UR plan must provide for review for Medicare and
Medicaid patients with respect to the medical necessity of:
– Admissions to the institution
– Duration of stays
– Professional services furnished, including drugs and biologicals
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34
Concurrent UM Still Matters
• “Use of Condition Code 44 or Part B inpatient billing pursuant to
hospital self-audit is not intended to serve as a substitute for
adequate staffing of utilization management personnel or for
continued education of physicians and hospital staff about each
hospital’s existing policies and admission protocols.”
–
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Page 50914, 2014 IPPS
35
Components Required for an IP
Claim
1.
Expectation/completion of a 2-midnight stay
⁻ UR review must ensure expectation of 2 midnights is “reasonable”
2.
Medical Necessity
⁻ UR review must establish hospital level of care is needed to care for the
patient
3.
Physician certification/documentation signed by the physician prior to DC
⁻ Order, reason for inpatient services, expectation and plan for posthospital care
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36
What is Medical Necessity?
• Is the physician's expectation of 2 midnights reasonable?
– Achieved with criteria? PA evidence based determination? Other?
• Is hospital level of care needed to care for the patient?
– Ensure no care for convenience, no delays in treatment/testing or
custodial
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Admission Review – Key
Considerations
Initial review for expectation of Length of Stay (LOS)
• Physician documentation of an expectation of 2-midnight stay generally falls into
three categories:
– Supports expectation of 2-midnight stay
• “I expect this patient to remain in the hospital for longer than…”
• Expected LOS > 2 midnights (in document signed by physician)
– No documentation/conflicting documentation
– Clearly conflicts with or fails to support expectation of 2-midnight stay
• Order – “Discharge in am” (when care has not already crossed at least one
midnight)
• Progress note – “anticipate d/c in am” (when care has not already crossed at
least one midnight)
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38
Recommended Hospital Work Flow
Expected LOS greater than 2 midnights or unclear
Yes
Patient
presents at
hospital*
Validate or
obtain order
change
Inpatient
criteria met
No
Physician
Advisor
Review
Review
elements of
certification
Inpatient
recommendation
Validate or
obtain order
change
Review
elements of
certification
Observation/
Outpatient
recommendation
Validate or
obtain order
change
Re-review as
new
information is
available
Follow this process when:
•
•
Physician documentation of expected discharge is greater than 2 midnights; or
There is no documentation of expected discharge
* Patient hospitalized for condition other than Inpatient Only Procedure List
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39
Recommended Hospital Work Flow
Expected LOS less than 2 midnights
No +
Yes
Patient
presents at
Hospital*
Resolve conflict
between order
and
expectation
Expectation
correct?
Yes
Condition
Code 44
Obtain order
change
IP order?
Yes/
observation
No
Observation
criteria met?
No/
obtain order
change
Re-review as
new
information is
available
Follow this process when:
•
Physician documentation of expected discharge is less than 2 midnights
* Patient hospitalized for condition other than Inpatient Only Procedure List.
+If the expectation is not correct, follow the workflow for an expected length of stay of greater than two midnights.
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40
Considerations Regarding the Time
of UR Review
•
Review at admission:
– IP
– 2+ midnight expectation AND medical necessity established AND physician
certification complete
–
Observation/Outpatient
– Expectation of <2 midnight stay and medical necessity established
–
NOTA
– Review for documentation of care for convenience, a delay in treatment/testing or
custodial care
•
Review after 1+ midnight:
– IP
– 2+ midnights completed or expected AND medical necessity established AND
physician certification complete
–
Observation status should be rare after 2 midnights
–
NOTA
– Review for documentation of care for convenience, a delay in treatment/testing or
custodial care
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41
Summary
•
“Get It Right” while the patient is in the hospital and as
early in the stay
as possible
– Implications for hospital, patient and physician
•
Admission review – key considerations:
– Order
– Expectation
– Medical Necessity
– Documentation and Certification
•
Rebill when appropriate
•
While the time requirement has evolved, the science at
the core of medical necessity remains the same
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Master title
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42
Questions?
Ralph Wuebker, MD, MBA
Chief Medical Officer
Executive Health Resources
[email protected]
484-844-2485
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43
2 Midnight Example 1
Symptoms:
80 year old female admitted with chest pain, positive biomarkers and EKG
changes in the emergency room, urgently taken to catheterization lab
Order
• Admit as inpatient
Expectation
of LOS
• “I expect this patient to remain in the hospital for a time greater than 2
midnights”
Medical Necessity
• Documentation present to support inpatient admission
Certification
• All elements of certification present per document review
Follow up necessary
• Patient does not remain for 2 MN
• Was (presumption not met) due to: death, transfer, AMA,
inpatient-only procedure or “recovery faster than anticipated”?
• Evaluate based on start of service to see if benchmark met
©2014 Executive Health Resources, Inc. All rights reserved.
44
2 Midnight Example 2
Symptoms:
65 year old male, no previous cardiac history, presents with shoulder pain after
exertion, physician suspects musculoskeletal, biomarkers below detection threshold,
no EKG changes. Monitor overnight if telemetry, enzymes and EKG’s remain
negative, anticipate discharge in am. No planned stress test or further evaluation
during hospitalization.
Order
• Admit as inpatient
Expectation
of LOS
• 23 hour monitoring
Medical Necessity
• Documentation does not support inpatient admission – observation
Certification
• Order and physician expectation of 2 midnights are in conflict
• Order and medical necessity are in conflict
Follow up necessary
• Consider Condition Code 44 if requirements are met
• If patient remains in hospital or new information available, re-review for medical
necessity at inpatient level
• If patient discharged – cannot do Condition Code 44, if within rebilling timeframe,
consider for Part B rebilling
©2014 Executive Health Resources, Inc. All rights reserved.
45
2 Midnight Example 3
Symptoms:
78 year old female admitted for atrial flutter, stabilized in Emergency Room. Although
expected to be discharged after medication adjustments, patient developed heart block
requiring additional adjustments and possible pacemaker
Order
• Place in observation
Expectation
of LOS
• Anticipate short stay, 23 hour monitoring
Medical Necessity
• Delayed review suggests that inpatient may be appropriate
Certification
• All elements of certification would need to be completed prior to discharge
Follow up necessary
• EHR would recommend inpatient level of service
• Call with physician to discuss medical necessity in light of order change requirement
• Call with case manager to discuss order change and expectation documentation with
regard to certification requirements
• Inpatient order, documentation of expectation and all other elements of certification
would need to be addressed prior to discharge
©2014 Executive Health Resources, Inc. All rights reserved.
46
2 Midnight Example 4
Symptoms:
76 year old woman with UTI, treated with intravenous antibiotics. Fevers continue
with tachycardia and hypotension requiring fluid support. Immunosuppressed due to
post kidney transplant status.
Order
• Admit for inpatient services
Expectation
of LOS
• Admission orders include order for “discharge in am”
Medical Necessity
• Would meet for inpatient by criteria, but documentation clearly violates 2 midnight
expectation
Certification
• Depending on follow-up activity, if inpatient supported confirm all elements of
certification prior to discharge
Follow up necessary
• Although historically inpatient medical necessity would be met, the documentation
does not support 2 MN expectation
• Resolve conflict between order/medical necessity and expectation
• Update documentation if patient not discharged as planned
• Consider Condition Code 44 if expectation of discharge remains
©2014 Executive Health Resources, Inc. All rights reserved.
47
2 Midnight Example 5
Symptoms:
68 year old male, with a history of stroke, known carotid stenosis, and previous neck
irradiation making carotid end-arterectomy high risk. Patient scheduled for carotid
angiography and stent placement.
.
Order
• Observation
Expectation
of LOS
• Less than 2 midnights
Medical Necessity
• Procedure appropriate for inpatient based on inpatient-only status
Certification
• All elements of certification except the 2 MN expectation would be required to be
documented prior to discharge to support inpatient claim
•
•
Follow up necessary
•
©2014 Executive Health Resources, Inc. All rights reserved.
Order should be corrected for procedure on CMS inpatient-only procedure list
For procedures on the inpatient-only list, order must be present on the medical
record prior to the initiation of the procedure
Inpatient-only procedures are exempted from the 2 midnight expectation, but all
other certification requirements remain
48
About Executive Health Resources
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EHR has been awarded the exclusive endorsement of the American Hospital
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award recognizes EHR’s achievements in creating a positive work environment
that attracts and retains employees through a combination of benefits, working
conditions, and company culture.
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©2014 Executive Health Resources, Inc.
All rights reserved.
No part of this presentation may be reproduced or distributed.
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