Transcript Getting it Right the First Time: Documentation of Medical Necessity for Short Stay Patients Steve Lokensgard Special Counsel Faegre & Benson David Orbuch President Phillips Eye Institute fb.us.3575960_2

Getting it Right the First Time:
Documentation of Medical Necessity for Short Stay Patients
Steve Lokensgard
Special Counsel
Faegre & Benson
David Orbuch
President
Phillips Eye Institute
fb.us.3575960_2
AGENDA
The Need to Get This Right!
Medicare Criteria for Inpatient Admissions
Process for Small Hospitals
Process for Large Hospitals or Health Systems
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AGENDA
The Need to Get This Right!
Medicare Criteria for Inpatient Admissions
Process for Small Hospitals
Process for Large Hospitals or Health Systems
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The RAC Demonstration
• Top Services with RAC-Initiated Overpayment Collections
• Treatment in wrong setting for:
– Surgical procedures
$88 million
– Cardiac defibrillator implants
$64.7 million
– Heart failure and shock
$33.1 million
• Wrong setting means the patient could have been treated on an
outpatient basis
• Accounts for almost 20% of the RAC overpayments
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Non-RAC Reasons to Document Correctly
• December, 2007
– St. Joseph’s Hospital pays $26 million to the
federal government to settle a qui tam lawsuit
involving short stays not medically necessary
• June, 2008
– 75% of one-day stays for chest pain in the State of
Minnesota were not medically necessary and could
have been treated on an outpatient basis according to
Stratis Health, Minnesota’s QIO
• State False Claims Act
• Quality of Care
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AGENDA
The Need to Get This Right!
Medicare Criteria for Inpatient Admissions
Process for Small Hospitals
Process for Large Hospitals or Health Systems
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Medicare Criteria for Inpatient Admissions
• No magic language to document
“Neither the statute nor any applicable regulation defines “inpatient.”
CMS’s policy manual defines an inpatient as a person who has been
formally admitted to a hospital.”
– Landers v. Leavitt, 545 F.3rd 98 (2nd Cir., 2009)(emphasis added)(referring to
the Medicare Benefit Policy Manual)
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Medicare Criteria for Inpatient Admissions
• Medicare Benefit Policy Manual, ch. 1, § 10
– 24-hour benchmark
– Complex medical judgment
• Patient’s history and current medical needs
– Severity of signs and symptoms exhibited by patient
– Medical predictability of something adverse to happen
– Need for outpatient diagnostic studies to assist in assessing
whether the patient should be admitted
– The availability of diagnostic procedures where the patient presents
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Medicare Criteria for Inpatient Admissions
• Medicare Benefit Policy Manual, ch. 1, § 10
– Types of facilities available to inpatients and outpatients
– Hospital’s by-laws and admission policies
– Relative appropriateness of treatment in each setting
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Medicare Criteria for Inpatient Admissions
• CMS Ruling 95-1
– Medicare contractors must act in accordance with Medicare statutes,
regulations, national coverage instructions, accepted standards of medical
practice and CMS rulings
– Accepted standards of medical practice:
• Published medical literature
• A consensus of expert medical opinion
• Consultations with their medical staff, medical associations, including local
medical societies, and other health experts
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CMS Recommended Best Practice
• Hospital Payment Monitoring Program Compliance Workbook
– Physicians should adopt screening criteria that can be used by Utilization
Management Staff (e.g. InterQual, Milliman)
– Cases failing screening criteria should be referred to physicians for review
– The ultimate decision to admit must be made by a physician, “either through
the use of physician approved or developed criteria, or through a physician
advisor.”
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AGENDA
The Need to Get This Right!
Medicare Criteria for Inpatient Admissions
Process for Small Hospitals
Process for Large Hospitals or Health Systems
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Small Hospital Process
• Phillips Eye Institute – the Midwest’s only
Specialty Eye Hospital
– Serving over 16,000 patients per year
– Significant Medicare patients
– 350 inpatient admissions per year
(dropping every year)
– 170 Physicians on the Medical Staff
(non-employed model)
– 180 employees
– Significant changes in opthalmology practices over last 10 years
– Recent implementation of electronic medical record
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Small Hospital Process
• Mock Joint Commission Audit in 2004
– Raised concerns about the documented
medical necessity of inpatient stays
– Some records lacked a clear order for admission
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Small Hospital Process
• Action Steps
– Medical Staff Quality Improvement and Credentialing Committee reviewed
the hospital’s utilization review criteria – significant debate
– Considered InterQual criteria
– Modified hospital’s Admission Standards in August, 2005
– Educated physicians and nurses on standards
– Developed order sets and documentation tools
– Encouraged communication among treatment team
– Monitored documentation of admissions
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Small Hospital Process
• Effect of changes
– Resulted in a better understanding of the need
for documentation
– Impact on care to patient population
– Change in nurse/ doctor relationship
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Small Hospital Process
• Western Integrity Center (WIC) Audit in 2005
– A Medicare Program Safeguard Contractor
– RAC Like – WIC used data mining and found a high percentage of
admissions following procedures not on Medicare’s inpatient-only list
– Reviewed a sample of claims from period prior to changes
– Identified same issues we had identified
– Took comfort in knowing that we had already fixed the issues identified in the
audit, and limited future exposure
– Payment made to Medicare
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AGENDA
The Need to Get This Right!
Medicare Criteria for Inpatient Admissions
Process for Small Hospitals
Process for Large Hospitals or Health Systems
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Large Hospital Process
• Action Steps
– Educate physicians
• Article on inpatient v. observation delivered to every physician on medical staff
• Clarity around documenting admission orders
• Classes for hospitalists and ED physicians
– Retroactive Monitoring
• Applied InterQual criteria
• Spike in observation cases
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Large Hospital Process
• Action Steps
– Considered Admit-to-Case-Management Protocol
• Scott & White Memorial Hospital in Temple, Texas
• MetaStar, Inc. study in the Wisconsin Medical Journal
• Not accepted as a valid admission order by Minnesota’s Fiscal Intermediary
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Large Hospital Process
• Action Steps
– Concurrent Admission Review Process
• Designated nurses perform concurrent review of admissions and observation
cases 7 days per week, 16 hours per day
• Goal: review between 12 and 24 hours
• If case fails InterQual, refer to a physician advisor
• Physician advisor provides advice on admission v. observation
– Will call admitting physician if necessary to ask questions about what was
documented
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Large Hospital Process
• Action Steps
– Orders
• Order sets in Electronic Medical Record revised
• Two designated HUCs check regularly for orders and ensure that admission
review process was followed
• Two HUCs – only people authorized to change a patient’s status
• Coders also review for orders before bill drops
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Large Hospital Process
• Effect of Changes
– New relationship between nurses, physicians,
and physician advisors
• Similar to relationship between coders
and physicians
• Don’t need to understand all of the Medicare rules,
but need to know how to document
– Care?
– Revenue Cycle Improvement
– Confidence going into RAC Audits
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Summary
• Small Hospital Process
– Medical Staff participation
– Education
– Could be used by departments within large
hospitals
• Large Hospital Process
– Familiarize physicians and staff
– Concurrent review of cases
– Second-level review by physicians/ physician advisors
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QUESTIONS?
Steve Lokensgard
David Orbuch
(612) 766-8863
(612) 775-8815
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Getting it Right the First Time:
Documentation of Medical Necessity for Short Stay Patients
Steve Lokensgard
Special Counsel
Faegre & Benson
David Orbuch
President
Phillips Eye Institute