CMS: Moving Forward on Medically Questionable Admissions

It appears CMS is mounting a two pronged crusade against medically inappropriate admissions. On August 3, 2012 the agency announced the beginning of the prepayment reviews for hospitals in troubled states. Those with higher rates of improper claims payments include California, Florida, Illinois, Louisiana, Michigan, New York, and Texas. They are also targeting four states with historically high claim volumes of short stays including Missouri, North Carolina, Ohio, and Pennsylvania.  The go-live date for this initiative is August 27, 2012.

The second prong was discussed on the July 18 open-door forum call-in regarding the latest in OPPS rulings. CMS is not so much questioning the medical necessity of care provided as they are the appropriateness of the site- of- service. They are aware that determining inpatient versus observation status is challenging, especially for those hospitals that do not have 24/7 case managers or utilization review access. And Condition Code 44 with its accompanying compliance requirements has never been user friendly. CMS is looking to the industry for suggestions on how to simplify compliance, reduce extended ‘observation’ stays, and protect beneficiaries from the financial burden of unexpected Part B charges for care not covered under Part A.

My Take

This problem has been around for a while. I’ve been personally involved in the Condition Code 44 process and it is not popular with nurses, physicians, patients or families. Telling a patient who is already in a hospital gown, lying in a hospital bed, and ordering his hospital meals for the next day that he is really an outpatient is often not met with equanimity. I know CMS created a brochure for beneficiaries that suggests they ask the hospital about their patient status,  but come on – should a sick person, or a sick elderly individual usually entering the facility via the ED be responsible to negotiate patient status after their doctor told them they need to stay in the hospital? Another problem is the nasty shock when the patient’s bill arrives detailing all the non-covered Part B services.  I’m glad CMS is moving forward; I know the idea of prepayment review is onerous. But hopefully the reviews will reveal trends that can be better managed. I believe they will find some perfectly reasonable short stays. Perhaps the DRGs that likely represent the short stay diagnoses need a LOS outlier and short stay fee schedule?  But, of course, for any of this to work,  it will require complete and thorough clinical documentation to support the medical decision-making involved with assigning patient status…and you know where we stand with that.

Barbara Aubry is a Regulatory Analyst with 3M Health Information Systems.

One response to “CMS: Moving Forward on Medically Questionable Admissions

  1. Medicare Advantage plans are uniquely positioned to review the appropriateness of “medical necessity” and “site of service” as part of the managed network’s prior authorization requirements. Yet, even with such a powerful tool, changing behaviors remains a challenge.

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