Case Management Corner: A Nurse Case Manager or a Social Work Case Manager?

By Kelly Bilodeau

Nurse case managers and social workers were once a natural pairing, working in tandem to support the patient.

“The idea was that nurses would handle medically complex issues while social workers would focus on social needs,” said Tiffany Ferguson, LMSW, CMAC, ACM, CEO of Phoenix Medical Management Inc.

However, due to changing paradigms and a more challenging patient population, case managers and social workers today often find themselves stepping on each other’s toes, and it’s becoming increasingly clear that it’s time to rethink traditional roles, she said.

A Changing Role

Case management is undergoing a transformation, thanks to patient and care-related changes. “Length of stay is shorter. We’re more efficient,” Ferguson said. “Patients are simultaneously medically and socially complex.” A case manager needs to be able to handle both aspects.

While case management was once primarily the domain of nurses, who perceived the job as a step up from the bedside, that changed during the COVID-19 pandemic. Hospitals were forced to make nursing jobs more appealing to retain and attract staff members during the crisis.

“Now the incentives for a floor nurse are way better than they are for a nurse case manager,” says Ferguson. Not surprisingly, fewer nurses are making the shift. Instead, when many floor nurses decide to leave the bedside they are selecting remote positions or to pursue advanced training to become nurse practitioners, she said.

At the same time, case management has become increasingly appealing to social workers. “There’s an ample pool of social workers who are coming into the marketplace and want to work in healthcare,” Ferguson said. They’re stepping into roles at hospitals that are either a split nurse/social worker model. “Or they could be doing the same exact job as a nurse case manager,” Ferguson said.

Rethinking Hiring

To solve these issues, directors need to stop thinking about whether it’s best to hire a nurse or a social worker and instead start hiring the individual with the most potential as a case manager. This is someone with solid social skills who works well at the patient’s bedside and can communicate effectively with floor nurses, physical therapy staff, and physicians. “They have to be a go-getter, really autonomous at filling their day and getting everything accomplished with patients. They have to have good boundaries, and be skilled with technology,” Ferguson said.

From there, training can fill the gaps.

For a social worker, an onboarding program might focus on how to handle the medical complexities of the role, anticipating care pathways, medication protocols, and navigating prior authorization requirements.

Conversely, a nurse may need more education on social factors. However, as nursing becomes increasingly specialized, these candidates may perform some, but not all, aspects of care. They may also need additional training on how medical conditions and care plans translate to proactive transitional needs for the patient. For example, at many facilities, discharge and admission are handled by separate team members, so a bedside nurse may no longer be as adept at performing a history and physical or in anticipating the patient’s post-acute needs.

“It's not like it used to be where one nurse did all of it,” Ferguson said.

Onboarding and orientation should be tailored to the individual. “You can't assume based on the person's professional license that they're going to come in skilled enough and know how to do the job,” Ferguson said. The job has grown so challenging that even an adept case manager requires continual ongoing training to stay up to date, she said.

Overall, hiring decisions should no longer be about choosing between a nurse and a social worker. It’s about identifying adaptable, skilled professionals and giving them the tools they need to succeed, Ferguson said.

Case Management Corner is your go-to source for insightful discussions on relevant topics in case management. Through an engaging interview-style format, our team members share their expertise, experiences, and best practices to keep you informed and empowered. Whether you're looking for industry updates, practical strategies, or real-world perspectives, we bring you valuable conversations designed to enhance your knowledge and support your professional growth. Stay tuned for expert insights straight from the field! Kelly Bilodeau has been a longtime writer for HCPro’s Case Management Monthly. 

Ensuring Compliance with Condition Code W2 and 44 Processes

By Juliet Ugarte Hopkins, MD, ACPA-C

Condition Code W2 (CCW2), referred to by some as a “Medicare self-denial” or “Medicare Part B rebilling,” has been around for over a decade, since it was initially referred to in Chapter 6 of the Medicare Benefit Policy Manual. Dr. Alvin Gore, member of the Emeritus Board of the American College of Physician Advisors, wrote for RACmonitor.com back in May 2019, comparing CCW2 to Condition Code 44 (CC44). He recommended hospitals attempt to utilize the latter process over the former, opining that the CC44 process was more efficient, from a billing and reimbursement standpoint, and more transparent, from a patient status standpoint. 

I agree with Dr. Gore, and also refer to the Centers for Medicare & Medicaid Services (CMS) direction in the Federal Register from August 2013, which includes the following:

“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. As education and staffing efforts continue to progress, inappropriate admission decisions, and the need for hospitals to correct inappropriate admissions or report Condition Code 44, should become increasingly rare.” 

This clearly states that hospitals may not default to CC44 or CCW2 to address lack of utilization review (UR) coverage, physician advisor coverage, or medical staff education about patient status assignment. Unfortunately, this continues to be a strategy for many hospitals challenged with staffing limitations.

Similarly, hospitals must ensure that they are compliantly following all of the steps in the CC44 and W2 processes. In 2021, I wrote in-depth about CC44, deconstructing the concepts between the code itself and the mandated Medicare process. While the CCW2 process applies to Medicare cases only, it’s imperative to understand that the details must be followed, no matter how complex and daunting they feel to carry out. Indeed, as Dr. Gore illustrated in 2019, the CCW2 process is complicated and time-intensive. However, it’s also mandated by CMS – and is not optional.

A common practice for retrospective “Medicare short stay” reviews involves Medicare patients discharged from the hospital in inpatient status following a hospitalization lasting fewer than two midnights. I believe that best practice extends this sampling to patients hospitalized for fewer than three midnights, capturing potential cases wherein an overzealous clinician or utilization manager changed the patient’s status to Inpatient solely based on the passage of a second midnight, without considering the medical necessity. 

CMS notes that there are specific caveats to the Two-Midnight Rule, including death, transfer to a higher level of care, and others, wherein inpatient billing is still appropriate, even if the hospitalization did not involve at least two midnights. Following review by an experienced utilization nurse, these cases should pass along to billing for completion as-is. Tricky cases, where it’s not clear if the patient who left against medical advice (AMA) early in the morning on hospital day two actually had a condition supporting a two-midnight anticipation on hospital day one, or all of the cases for which the “patient improved more quickly than anticipated” is referenced in the documentation, should be referred to a physician advisor for additional review.

If the physician advisor does not feel that the documentation supports a two-midnight anticipation, which would support Medicare re-billing under Part B, they must reach out to the physician who entered the inpatient order. Notification need not be lengthy, but should include the following points:

1. Retrospective review of the case does not find a two-midnight anticipation was warranted and (briefly) why;

2. The hospital plans on billing the case as outpatient to Medicare Part B instead of inpatient to Medicare Part A, but this does not affect or apply to provider billing;

3. The physician has an opportunity to disagree with the decision and must respond to request further discussion with the physician advisor by a specific deadline; and 

4. If the deadline passes and there is no response from the physician, Part B re-billing will proceed.

In the event the physician disagrees, there must be a discussion between her/him and the physician advisor. If the physician provides additional information that persuades the physician advisor that inpatient billing criteria was met, the physician advisor should pass the case along for Medicare Part A billing and advise the physician to include the missing clinical information in their H&P, progress note, or discharge summary, as appropriate. If the physician and physician advisor continue to disagree, a second physician on the hospital’s utilization management committee (UMC) should be required to review the case and weigh in. If this second UR physician agrees with the clinician that inpatient status was supported, the claim goes forward with Medicare Part A billing. If the second UR physician agrees with the physician advisor, the claim is re-billed to Medicare Part B.

Finally, patients associated with claims re-billed to Medicare Part B must be notified by the hospital. This can be automated within the electronic health record, utilizing a templated letter format, but should include information about where and how the patient can contact the hospital to discuss the situation, if they wish. 

How is your hospital reviewing and managing CCW2s? Is your physician advisor or other physician member of the UMC involved? Are attending physicians receiving notification and allowed a chance to respond? Are patients notified of the change in their claim? If you’re not sure, I encourage you to investigate and confirm that the process is being followed compliantly.

The CMS WISeR Model: A Targeted Approach To Expand Prior Auths

By Tiffany Ferguson, LMSW, CMAC, ACM

The Centers for Medicare & Medicaid Services (CMS) has announced the establishment of the Wasteful and Inappropriate Services Elimination and Reduction (WISeR) Model, a six-year initiative launching Jan. 1, 2026.

This so-described voluntary model (although in reading the guidelines, it becomes clear it is very much mandated for the six states) introduces a structured, technology-enabled approach to prior authorization and pre-payment review for selected Medicare Part B services deemed to be of low clinical value, overused, or associated with fraud, waste, and abuse.

The WISeR Model represents a significant evolution in the CMS oversight strategy. Historically, the use of prior authorization by Medicare has been limited to targeted service categories such as durable medical equipment (DME), non-emergency transportation, or certain outpatient procedures. WISeR is the first push to pair broad-scale, claims-based utilization analytics with Medicare Administrative Contractor (MAC)-directed pre-payment medical necessity review for professional and outpatient services.

As noted, WISeR will be implemented across six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. These states were selected based on Medicare volume, geographic diversity, and alignment within four existing MAC jurisdictions:

• JL (New Jersey);

• J15 (Ohio);

• JH (Oklahoma, Texas); and

• JF (Arizona, Washington).

Each participating state will serve as a testing ground for evaluating changes in service utilization, program integrity, and cost savings.

Providers in the six participating states will be required to either submit prior authorization requests for these services or accept a pre-payment review upon claim submission. Instead of the MACs, from the ruling, CMS will be using designated contractors, under MAC oversight, that will determine whether claims meet established medical necessity criteria. The ruling also mentioned the provision of this group to utilize artificial intelligence (AI)-enabled tools.

The specific procedures and devices that CMS has identified include the following:

• Electrical Nerve Stimulators (NCD 160.7);

• Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18);

• Phrenic Nerve Stimulator (NCD 160.19);

• Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease (NCD 160.24);

• Vagus Nerve Stimulation (NCD 160.18);

• Induced Lesions of Nerve Tracts (NCD 160.1);

• Epidural Steroid Injections for Pain Management excluding facet joint injections (L39015, L33906, L39036, L39240, L39242, L36920, L38994, L39054);

• Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L33569, L34106, L34228, L38201, L34976, L35130, L38737, L38213);

• Cervical Fusion (L39741, L39799, L39770, L39758, L39762, L39793, L39773, L39788);

• Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (NCD 150.9);

• Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (L38276, L38307, L38398, L38387, L38310, L38312, L38385, L38528);

• Incontinence Control Devices (NCD 230.10);

• Diagnosis and Treatment of Impotence (NCD 230.4);

• Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis (NCD 150.13);

• Skin and Tissue Substitutes (LCDs below) – only applicable to MAC jurisdictions and states that have an active LCD in place;

• Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (L35041); and

• Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities (L36690).

An interesting consideration in the ruling, mentioned as an exploration, is the CMS provider safeguard known as “provisional affirmation.” If a claim is not affirmed, providers would receive a detailed rationale and may resubmit or appeal the determination.

Additionally, organizations demonstrating an affirmation rate of more than 90 percent over time may qualify for a gold-carding exemption, temporarily removing them from the prior authorization requirement, similar to commercial plans.

Financially, CMS will compensate the third-party reviewers not on volume, but based on a share of the Medicare expenditures they help avert, ensuring alignment with the CMS goals of reducing low-value care and reducing waste.

While inpatient services are not directly subject to the model, the ripple effects on outpatient surgery, interventional procedures, and medical device utilization will require cross-functional coordination. Surgical locations will want to have a clear understanding of the required medical guidelines for procedural authorization and approval. Clear, evidence-based documentation will be critical for both prior authorization requests and appeals.

WISeR reflects the CMS continued movement toward proactive utilization management, with an invested approach toward leveraging technology and a commercial payer approach. While the model is currently limited to six states and select services, its structure suggests a potential framework for broader application.

CMS Transitions Inpatient Hospital Short-Stay Reviews to the MACs

By Tiffany Ferguson, LMSW, CMAC, ACM

I’d like to begin with a thank-you to Dr. Stephanie Van Zandt, Medical Director of Physician Advisor Services at BayCare, for sharing this news.

The Centers for Medicare & Medicaid Services (CMS) is shifting the responsibility for inpatient hospital short-stay reviews from the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) to the Medicare Administrative Contractors (MACs), effective Sept. 1. According to the Inpatient Hospital Reviews FAQs | CMS, the justification for this change is to allow the BFCC-QIOs (Acentra Health and Livanta) to focus their efforts on quality improvement and expedited appeals. 

With the additional time afforded to the BFCC-QIOs, they will be shifting their focus to other quality-related functions, such as higher-weighted DRG reviews, hospital discharge appeals, and quality-of-care concerns. This realignment allows QIOs to focus on broader quality improvement initiatives, while MACs, already responsible for various audit and compliance efforts through the existing Targeted Probe-and-Educate (TPE) program, will bring greater oversight to short-stay reviews.

The inclusion for prepayment reviews on hospital short stays will now be prioritized for review under the MAC-led Targeted Probe and Educate (TPE) program. According to the FAQs from CMS, a hospital short stay is defined as a length of stay that is fewer than two midnights after inpatient admission. While such admissions may be clinically appropriate, CMS has identified them as having a higher risk category for improper payments. These reviews will be performed by registered nurses (RNs) with available access to the MAC’s medical director(s).

These reviews will evaluate patient status documentation to ensure that each patient’s condition supports the need for inpatient hospital services, in accordance with 42 C.F.R. § 412.3(d) and not proprietary commercial screening tools like InterQual or MCG.   

MACs will apply the existing TPE program, which uses data analytics to identify providers with outlier billing patterns. MACs will conduct these reviews on a prepayment basis, giving providers the ability to rebill Part B when Part A payment is denied, or pursue the further appeals should the provider disagree, in accordance with the Medicare appeals process. According to the details, this prepayment review will be completed with a sample of 20-40 claims per provider, as a round of review. Providers may have a total of up to three rounds before they are referred to CMS for additional administrative action.

CMS and the MACs have outlined an implementation plan that includes educational outreach, updated guidance in the Program Integrity Manual, and MLN communications. This transition will not change CMS’s patient status policies, nor diminish the importance of a physician’s clinical judgment. However, hospitals must now ensure that documentation clearly supports the need for inpatient care under the two-midnight rule. With MACs leading these reviews, providers can expect more targeted oversight, demonstrating CMS’s commitment to reduce waste and abuse.

New Requirements in CMS’ Conditions of Participation Regulations

By Tiffany Ferguson, LMSW, CMAC, ACM

Effective July 1, a subtle but significant expansion for the Centers for Medicare & Medicaid Services (CMS) added new requirements to 42 CFR § 482.43 regarding transfer protocols. Originally mentioned back in November 2024 as part of the CY 2025 Outpatient Prospective Payment System (OPPS) Final Rule, CMS announced the finalization of new requirements in conjunction with the maternal healthcare news briefs.

However, likely during the political change of offices, an interesting proactive statement was added to the Conditions of Participation (CoP) regulations that require acute-care hospitals to develop and implement written transfer protocols.

The finalized regulation, outlined in § 482.43(c), mandates that all acute-care hospitals have written policies and procedures governing intra-hospital and inter-hospital transfers. These include the following:

• Transfers from the emergency department to inpatient admission;

• Transfers between units within the same hospital; and

• Transfers between different hospitals for higher levels of care or specialized services.

While the transfer of patients between hospital units or facilities has long been a routine operational function, CMS is now moving to standardize and elevate the practice as a core compliance obligation, focused on improving patient safety, care transitions, and timely access to appropriate levels of care. This rule codifies what many hospitals already do, transferring patients from the ED to hospitalized patient units, between units, and to other facilities. But now, these processes must be formally documented in written policy, implemented organization-wide, and supported with annual training for designated staff.

Hospitals are also required to conduct annual training for relevant staff on these transfer protocols. Notably, CMS leaves flexibility for hospitals to determine which staff are included, allowing adaptation based on organizational structure and resources.

However, given the unique ties of this additional standard with obstetrics, consideration should be given to hospital admissions and transfers in and out of the mother-baby unit. For hospitals to ensure appropriate compliance, it makes sense to audit and formalize existing transfer policies.

Consider review of the existing annual training provided to applicable clinical staff to meet the requirements for providing information regarding transfer protocols.

In reviewing the original guidance and comments in the CY 2025 OPPS ruling as to what led to this change, CMS cited the need to reduce delays, ensure continuity, and protect patients in particularly vulnerable populations, such as pregnant and postpartum individuals. Federal Register :: Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs, Including the Hospital Inpatient Quality Reporting Program; Health and Safety Standards for Obstetrical Services in Hospitals and Critical Access Hospitals; Prior Authorization; Requests for Information; Medicaid and CHIP Continuous Eligibility; Medicaid Clinic Services Four Walls Exceptions; Individuals Currently or Formerly in Custody of Penal Authorities; Revision to Medicare Special Enrollment Period for Formerly Incarcerated Individuals; and All-Inclusive Rate Add-On Payment for High-Cost Drugs Provided by Indian Health Service and Tribal Facilities

Case Management Corner: Why Are Case Managers Using The Same, Tired Framework?

By Kelly Bilodeau

Today’s case managers have digital tools, value-based goals, and post-pandemic challenges. So why are they still relying on a 1990s playbook?

For decades, hospitals have used the Triad Model: a case manager, social worker, and utilization review specialist committed to getting the patient out of the hospital as quickly and efficiently as possible, according to Marie Stinebuck, MBA, MSN, ACM, COO at Phoenix Medical Management Inc. However, as patient complexity rises, staff numbers shrink, and goalposts shift, this three-legged structure is buckling under modern demands, said Tiffany Ferguson, LMSW, CMAC, ACM, CEO of Phoenix Medical Management.

 It’s time for a new framework—the Adaptive Model, which Ferguson recently outlined in an article for CMSA Today.

Navigating post-COVID challenges

Many hospital officials recognize that the Triad Model is a problem, Ferguson said in a recent Finally Friday webinar.

“People are coming to us saying, ‘We need to look at this model. I don't think we have the right staffing mix,’” she said.

Job responsibilities feel muddled. Case managers and social workers often have overlapping responsibilities, which creates redundancies and confusion for patients. The Utilization Review (UR) role evolved significantly during COVID, as many positions transitioned to remote work. This shift altered the dynamics and collaboration within the inpatient care team. These factors put a drag on efficiency in a department that is already often understaffed and overburdened following a surge in pandemic-driven retirements.

At the core of these issues is an outdated system, way overdue for an update.

“Until readmissions became a key focus around 2012, case management remained primarily centered on discharge planning," Stinebuck said.

Since that time, hospitals have adopted integrated technology, including automated workflows and AI-driven case management software, and added post-acute partners. However, the foundational model hasn’t caught up.

Moving to a new approach

Where the Triad Model falls short in promoting proactive pre-hospitalization planning or addressing the social needs of patients, the Adaptive Model excels. It helps to eliminate redundancies between case management and social work.

“This new Adaptive Model looks at those roles. How do we complement each other without overlapping and work in the best interest of that patient?” Stinebuck said.

It also expands the tent, incorporating new team members, such as the physician advisor, a position formalized after the Triad Model’s inception, and non-licensed professionals. These non-licensed staff members reduce the burden on case managers by handling routine administrative tasks like scheduling outpatient appointments, arranging transportation, and delivering regulatory notices. This frees case managers to focus on more critical aspects of patient care and new goals, such as readmission prevention, addressing social determinants of health, and meeting value-based care targets.

The Adaptive Model also recognizes the time-saving value of integrated technology and expands interventions beyond inpatient units. Care has changed. The Adaptive Model follows patients into the emergency department, pre-surgical and hospitalized outpatient units, and even into their homes using telehealth.

Making the shift

Now, the goal should be to make changes that help case management meet patient needs in a world where efficiency is more crucial than ever. Case management no longer starts and ends in the hospital. Planning begins before admission, extends after discharge, and goes beyond simply pushing people through the system. The Adaptive Model is patient-centered and offers case managers the tools and the bandwidth to meet their needs at a time when demands often outstrip resources.

The old model is costing hospitals “time, money, and sanity,” said Ernie de los Santos, host of the Finally Friday webinar. It’s time to transition. The shift to the Adaptive Model isn’t just an evolution, “it’s a survival strategy,” he said.

Case Management Corner is your go-to source for insightful discussions on relevant topics in case management. Through an engaging interview-style format, our team members share their expertise, experiences, and best practices to keep you informed and empowered. Whether you're looking for industry updates, practical strategies, or real-world perspectives, we bring you valuable conversations designed to enhance your knowledge and support your professional growth. Stay tuned for expert insights straight from the field! Kelly Bilodeau has been a longtime writer for HCPro’s Case Management Monthly.

CMS Crackdown on Medicaid Coverage for Undocumented Patients Raises Red Flags

By Tiffany Ferguson, LMSW, CMAC, ACM

In a significant policy shift with wide-ranging implications for healthcare operations, the Centers for Medicare & Medicaid Services (CMS) announced that it will ramp up enforcement actions against states that use federal Medicaid dollars to provide healthcare to undocumented immigrants. This initiative, tied to a broader executive order focused on ending “taxpayer subsidization of open borders,” signals a more aggressive posture from the federal government and threatens to reshape how hospitals care for vulnerable patient populations.

While federal law has long restricted Medicaid funding to cover only emergency medical services for noncitizens without legal immigration status, CMS contends that states have stretched those definitions – often in the interest of delivering humane, cost-effective care. But under this new directive, such flexibility may soon come at a cost.

“Medicaid is not, and cannot be, a backdoor pathway to subsidize open borders,” said CMS Administrator Dr. Mehmet Oz in a press release. “We are putting states on notice – CMS will not allow federal dollars to be diverted to cover those who are not lawfully eligible.”

What’s Changing: Increased Oversight and Financial Consequences

As part of its enhanced oversight, CMS will begin focused audits of state Medicaid spending (CMS-64 reports), conduct in-depth reviews of financial systems, and assess eligibility rules to identify improper payments. The goal is to recoup federal matching funds from states that are out of compliance. CMS is also calling on states to urgently update internal controls, eligibility systems, and cost allocation policies.

These enforcement actions are expected to hit hardest in states that have, either through interpretation or legislative action, expanded Medicaid-funded emergency services to include treatments that CMS now deems outside the bounds of federal law.

States Like Arizona in the Crosshairs

Arizona offers one such example. The state has extended emergency Medicaid to include outpatient dialysis for undocumented individuals with end-stage renal disease (ESRD). Without access to routine dialysis, these patients would be forced into emergency-only care – a practice shown to increase hospital admissions, mortality rates, and healthcare costs.

The rationale behind Arizona’s policy, shared by several other states, including California, Illinois, and New York, is both humanitarian and practical: it reduces the frequency of emergency department visits, improves patient outcomes, and saves money by preventing crisis-driven care. However, under CMS’s new guidance, these expenditures may be deemed improper and subject to federal clawbacks.

This presents a critical challenge for Medicaid administrators and hospital systems: comply with stricter federal mandates or continue providing life-sustaining care with the risk of losing reimbursement.

Hospitals and Case Managers Face a Discharge Dilemma

Hospitals, especially those serving immigrant-heavy communities or functioning as safety-net providers, are already feeling the ripple effects. Case managers, who coordinate discharge plans and post-acute care transitions, routinely depend on emergency Medicaid to fund services such as skilled nursing facility transfers, home health services, and dialysis for undocumented patients. If CMS disallows these services, discharge planning becomes significantly more complex.

Patients who are medically ready for discharge but unable to access follow-up care due to immigration status or lack of funding may face extended hospital stays. This not only inflates length-of-stay metrics and strains inpatient capacity, but also creates financial burdens through uncompensated care. Alternatively, hospitals may be forced to discharge patients without adequate support, raising ethical concerns and increasing the risk of readmissions or poor health outcomes.

As CMS enforces tighter boundaries, case managers must rethink their workflows, collaborate more intensively with legal teams and charity care coordinators, and explore non-traditional partnerships with nonprofit organizations and faith-based groups to ensure that patient needs are met.

Medical Repatriation: A Legal and Ethical Minefield

When no viable discharge option exists in the U.S., hospitals may turn to medical repatriation: the practice of returning a patient to their country of origin for continued care. While not new, this approach is controversial, and raises significant ethical, legal, and reputational risks.

Increased federal scrutiny could unintentionally make repatriation more common. Patients who require long-term ventilator care, dialysis, or rehabilitation but have no insurance, public coverage, or family support may be identified as candidates for international transfer. However, this process is not straightforward. It requires coordination with foreign consulates, identification of a receiving facility abroad, and, ideally, the patient’s informed consent.

Legal advocates have long criticized repatriation as coercive when driven by hospital financial pressures rather than patient choice. Many patients may have lived in the U.S. for decades, have no access to care in their country of origin, or fear returning due to political instability or lack of support systems.

Still, without coverage options, hospitals may find themselves forced to explore every alternative – even those that would have once seemed untenable.

Fiscal and Ethical Tensions

Hospitals are caught between compliance mandates and their duty of care. In states like Texas, where a 2024 report estimated over $121 million was spent in a single month treating undocumented patients – and $25 million tied to Medicaid or CHIP – the potential financial impact of recoupments is enormous. For hospitals, that could mean reducing charity programs, downsizing staff, or shifting more uncompensated care onto the general operating budget.

At the same time, the directive undermines public health strategies that depend on early intervention and consistent care for chronic conditions. From a case management perspective, limiting emergency Medicaid to the strictest possible definition may seem fiscally prudent in the short term, but it ultimately drives up system-wide costs through avoidable hospitalizations, preventable complications, and legal challenges.

Looking Ahead: Preparing for a New Era of Compliance

Hospitals and health systems must begin preparing now. That includes:

• Reassessing current discharge planning protocols for undocumented patients;

• Training staff on the narrower definitions of Medicaid-covered emergency services;

• Evaluating the legal, ethical, and operational implications of repatriation; and

• Strengthening partnerships with community organizations, charity clinics, and legal aid groups.

The CMS crackdown is not just a bureaucratic shift; it’s a redefinition of how care is delivered to one of the most vulnerable populations in the U.S.

For hospitals and case managers, navigating this evolving terrain will require adaptability, ethical clarity, and a renewed focus on advocacy-driven care planning.

Embrace Your Physician Advisors’ Potential

By Juliet Ugarte Hopkins, MD, ACPA-C

The role of physician advisors has evolved into an absolute necessity in hospitals of all sizes around the country. As the healthcare landscape rapidly evolves, physician advisors have proven to serve as critical players, bridging the gap between confusion and clarity within clinical and administrative functions.

The role started as a loosely defined physician champion for case and utilization management teams. Only one or two individuals on a hospital’s medical staff generally gravitated to this position, usually as they were winding down in their career and looking to work fewer clinical hours. But, with the arrival of the Medicare Inpatient-Only list in 2000, nationwide Recovery Audit Contractor (RAC) audits in 2009, and creation of the Medicare Two-Midnight Rule in 2013, a new spotlight on hospital compliance, with mandates related to Centers for Medicare & Medicaid Services (CMS) rules and regulations, came into being.

As more and more physicians became well-versed in hospital service utilization, payment structures, and potential penalties related to compliance and quality metrics, these individuals moved beyond serving as mere support for nurse case and utilization managers. They were tasked with translating CMS requirements and payor guidelines about medical necessity and documentation to their colleagues in a way they could understand and put into practice. While undoubtedly frustrating, it increasingly became clear that a message about “the business of medicine” delivered to medical staff by a physician was received much more readily than the same message conveyed by a non-physician. 

In 2014, a number of these individuals – now with the common title of Physician Advisor – came together to form the American College of Physician Advisors (ACPA). This nonprofit, physician-led organization is now home to over 1,200 members, and serves as a testament to the evolution of the field. Physician advisors are now experts for adult and pediatric populations not only in case and utilization management, but also clinical documentation integrity, population health, quality initiatives and strategies, and much more. This role is an essential part of Condition Code 44 and W2 processes, which cannot be overlooked, from a compliance perspective. When considering hospital viability, in light of aggressive payor tactics involving medical necessity denials and DRG downgrades, physician advisors are particularly effective working with utilization management (UM) and clinical documentation integrity (CDI) leadership, in collaboration with medical staff.

While the role of physician advisor began as perhaps only one individual in a hospital who took on the rapidly growing needs of case and utilization management departments, a new staffing model has recently grown in popularity. More and more, hospitals are attempting to fulfill their needs by employing multiple physicians in fractions of full-time equivalents (FTEs) devoted to the physician advisor role. Instead of one physician working full-time, five rotate over the course of the month, assigned only 0.2 FTE for the efforts. Often, this leads to significant reduction of the focus and level of expertise provided by these physician advisors. Juggling patient care and potentially one or two other administrative roles can prevent these physicians from developing the level of expertise and familiarity they need to effectively function as a physician advisor. Especially in situations where they are never working with 100-percent focus on their physician advisor role – for example, when the vice president of medical affairs or medical director of a large hospitalist group is also serving as the physician advisor – it is almost impossible to address status escalations in a timely fashion or find time for creation and provision of routine education for medical staff and UM teams. 

If a hospital feels they can’t secure full-time physician advisors because there are individuals within the organization who are genuinely interested in the role, but aren’t ready to give up their clinical work, they should establish a full-time lead or chief physician advisor. This role will serve as the glue and ringmaster for the hospital’s physician advisory efforts, ensuing there is a consistent go-to person all staff is familiar with and relies on, no matter what the situation, day of the week, or time of day. Free from secondary review escalations, this individual can focus on studying data related to metrics such as medical necessity denials by payor according to primary diagnosis, readmissions, and utilization of Condition Code 44 and W2. The lead would also be responsible for ensuring the continuous education and proficiency of the other physician advisors on the team, including providing onboarding and mentoring support when new members are added.  As physician advisors become exponentially more common and valuable within hospitals and health systems, it’s important to understand how their impact can be inadvertently diluted through FTE spread. Consider combating against this by establishing a full-time lead physician advisor, or mandating that each physician serving in the role works at least 0.5 FTE, to ensure persistent mastery of and focus on the subject matter.

Case Management Corner: Trauma-informed Approach Improves Care For Patients

By Kelly Bilodeau

A hospital visit can be a stressful experience for anyone, but it may be particularly overwhelming for the more than 50% of Americans with a history of trauma. For those who have endured physical or emotional abuse, medical encounters can trigger panic, complicating treatment and sometimes leading to emotionally volatile encounters that can put medical staff members at risk.

“As a trauma therapist and clinical social worker in the emergency department, I often witness how standard medical practices can inadvertently retraumatize patients. Trauma-informed care transforms these encounters, allowing us to offer not just treatment, but healing,” said Kalie Wolfinger, manager of clinical services for Phoenix Medical Management.

In the past, providers often dismissed trauma-induced outbursts as bad behavior or a character flaw. However, there’s a growing recognition that these responses are not only a predictable reaction to traumatic events but also preventable and manageable with the right approach.

Training staff members in Trauma-Informed Care (TIC), a patient-centered communication approach, can improve care, follow-up, and outcomes, and avoid exacerbating the problem, according to Wolfinger.

The impact of trauma 

Many people think that trauma occurs in the wake of physical violence. However, a range of harmful experiences can traumatize patients, including accidents, natural disasters, serious or chronic illnesses, emotional abuse, neglect, racism or other forms of discrimination. Experts use the three E’s formula to understand how these experiences have affected patients, Wolfinger said. These are the Event, how the patient Experienced it, and its long-term Effect on them.

Research has shown that traumatic events can leave a lasting mark on people’s health. Adverse Childhood Experiences (ACES), for example, confer a higher risk of chronic illnesses, such as heart disease, depression, or substance use disorders. A hospital visit can exacerbate the problem, Wolfinger said, which is where TIC comes in. The model trains medical staff members to spot signs and symptoms of a trauma response and provide needed support without making the patient’s condition worse.

TIC is based on six guiding principles, according to the Substance Abuse and Mental Health Services Administration (SAMHSA):

• Safety

• Trustworthiness and transparency

• Peer support

• Collaboration and mutuality

• Empowerment and choice

• Cultural, historical, and gender sensitivity

Nowhere is this training more critical than in the ED, where emotions already run high. Many patients who come into the ED have experienced trauma in the past. Often those who’ve experienced childhood trauma avoid the doctor’s office and only seek care when it becomes an emergency.

Barriers to Implementation

While using TIC can be effective, many doctors aren’t familiar with the approach or even aware of how many of their patients have a trauma history. One survey found that only 16% of doctors believed that half of their patients had experienced trauma. Traditional constraints, such as a lack of time and resources, can also hinder TIC programs. Many hospitals are short-staffed, the workload is unrelenting, and burnout rates are high. Adding additional training and responsibilities is seen as an extra hurdle to overcome, Wolfinger said. However, organizations that invest the time can reap benefits, including improved safety for the care providers.

An effective TIC program starts with training on how to provide trauma-sensitive care and to de-escalate tense situations with stressed patients. It also implements screening procedures to flag patients in need of additional support and strives to improve the medical environment for patients. These include strategies such as increasing patient privacy, offering them more control over decision-making, and avoiding unnecessary physical contact.

“In my role as a trauma therapist in the emergency department, I’ve seen how medical exams can trigger severe trauma responses in patients. For example, I often write advocacy letters requesting modified physical exams for individuals with PTSD,” Wolfinger said. “These letters typically request accommodations such as allowing the patient to remain clothed, having a female provider present, and narrating care before physical contact. These small changes can dramatically reduce distress and prevent re-traumatization.”

Other procedural changes reduce the need for the patient to repeat upsetting details.

 “Another example from the ED involves survivors of human trafficking. When multiple agencies are involved, we work to minimize how often the individual has to repeat their story,” Wolfinger said. “Coordinating between departments ensures that care is not only trauma-informed but also efficient and respectful, reducing both emotional and procedural harm.”

Case managers should also strive to match patients who will need additional support after discharge with community organizations and programs in addition to providing strong advocacy throughout the process.

“Whether I’m supporting a survivor of human trafficking or writing a letter to request a modified physical exam, my role is about advocacy. Trauma-informed care isn’t a luxury. It's a necessity for dignity and safety in medical care,” Wolfinger said.

Case Management Corner is your go-to source for insightful discussions on relevant topics in case management. Through an engaging interview-style format, our team members share their expertise, experiences, and best practices to keep you informed and empowered. Whether you're looking for industry updates, practical strategies, or real-world perspectives, we bring you valuable conversations designed to enhance your knowledge and support your professional growth. Stay tuned for expert insights straight from the field! Kelly Bilodeau has been a longtime writer for HCPro’s Case Management Monthly.

Evolution of Case Management: Moving Beyond the Triad Model

By Tiffany Ferguson, LMSW, CMAC, ACM

Note: This article appears on CMSAtoday’s website at CMSA Today (CMSQ) - Issue 4, 2025 - The Evolution of Hospital Case Management: Moving Beyond the Triad Model.

Hospital case management programs have long relied on the triad model, a structure that includes nurse case managers, social workers and utilization review specialists. While this model served a clear purpose in the late 1990s and early to mid-2000s, changes in healthcare demands, hospital throughput challenges and technological advancements have made it less effective. Today, the complexity of patient care, increasing patient volumes and the need for streamlined care transitions require a revised approach. Many hospitals across the country are feeling the impact of this shift, as the traditional structure no longer aligns with the demands of current patient and hospital needs and limited staffing resources.

Some programs have already begun to evolve beyond the triad model but have yet to clearly define or brand this new approach. Enter the Adaptive Model: a post-COVID framework that recognizes the staffing changes, the importance of social determinants of health, our mental health crisis and the needs of an aging baby boomer population. This model acknowledges that patients are simultaneously socially and medically complex. The Adaptive Model integrates non-licensed professionals as key team members, leverages technological advancements and expands the focus from unit-based inpatient care management to emergency department (ED), pre-surgical and hospitalized outpatient populations. It also marks the movement of utilization review from the traditional case management structure to a revenue cycle framework, deserving its own place on the professional stage.

The triad model was designed to optimize patient care by coordinating medical, social and financial aspects of a patient’s hospital stay. In this model, the nurse case manager focuses on discharge planning, the social worker provides psychosocial support and the utilization review specialist (typically a nurse) ensures medical necessity and appropriate resource utilization. Although these are vital and imperative concepts, there are several inefficiencies that have emerged in the siloing of these functions in today’s current landscape. The most significant issue is redundancy and role overlap, which creates confusion between the demands for the case manager versus the professional licensure that one holds in the current employment marketplace. It is common practice now to see nurse case managers and social workers performing the same role and simply "splitting the unit" as the functions of case management in the acute care setting require a divide and tackle approach to address patient progression of care. The triad model, while historically effective, has several inherent limitations:

1. Redundancy and Role Overlap: Case managers, social workers and utilization review specialists often perform overlapping tasks, leading to inefficiencies in discharge planning and communication. This fragmentation causes confusion among patients and providers about the roles of different team members.

2. Unit-Based Structure Limitations: The traditional model prioritizes inpatient hospitalized patients. This approach fails to address the increasing number of patients who require complex transitional planning before formal hospitalization or surgery.

3. Failure to Recognize the Physician Advisor(s): Although physician advisors were not formally recognized until after the triad model was established, their oversight and function to the team has changed the programmatic design for the care management model. Physician advisors may have dynamic roles with utilization review, documentation integrity and addressing continued stays that are not medically necessary.

4. Limited Use of Non-Licensed Professionals: Similarly, the model fails to recognize the expansion of job functions to non-licensed professionals. The model hinders the evolved ability for professionals to work top of license due to the logistical demands of the role, reducing the time they can spend on high-value patient interactions.

5. Inadequate Technology Utilization: The model was created before the advancement of post-acute platforms, machine learning and automation. Many of the functions that require manual chart review can be more efficiently performed through technology support systems, changing the role for non-licensed and licensed team members.

6. Insufficient Focus on Patient Throughput: Although originally designed to support patient progression of care, the triad model was designed from a unit-based case management perspective. With rising emergency department volumes and an increasing emphasis on outpatient care, hospitals now require a model that emphasizes proactive care coordination before inpatient admission and well after the patient hospitalization under a more value-based/ population health structure.

7. Social Determinants and Patient Complexity: With new social determinants of health (SDoH) requirements and the rise of patient social complexity leading to greater social admissions, case management departments are forced to evolve and develop creative roles and specialized roles for social workers to tackle this population. Through time, this has also led to expansion of specialized case management roles for unique hospital populations such as palliative, oncology and obstetrics, to name a few.

8. The Shift of Utilization Review to Revenue Cycle: Utilization review (UR) has increasingly moved out of the case management structure, depending on hospital size, as its own program as a result of payer demands and a stronger focus on medical necessity and denials prevention. This greater alignment with revenue cycle does create some shifts for the traditional case management model, as many utilization review nurses are working remotely, handing some of the functions back to the case managers. This change, likely an article on its own, means utilization review is also changing away from a unit-based model to a functional model to evaluate patients across review and payer needs, leveraging technology for greater workflow efficiency.

The Adaptive Case Management Model

To address these inefficiencies, hospital case management must recognize the already in motion transition to a model that prioritizes:

1. The Inclusion of Non-Licensed Professionals

2. A Staffing Structure Focused on Technology and Skilled Communication

3. A Shift Away from Unit-Based Case Management

A key component of the new model is the strategic use of non-licensed professionals, such as case management assistants, patient navigators, care coordinators, community health workers, etc. These individuals are integral to the success of case management departments and require their own training and professional support to acknowledge the vital role they are serving to facilitate care transitions and support post-acute care services (McLoughlin-Davis, 2019). These individuals range from high school education, the patient care technicians, to associate and bachelor’s degree professionals who can support a wide variety of functions in the case management department. Now more than ever, these individuals are filling gaps in case management programs to address significant nursing shortages across the country. Some of the important services they provide include but are not limited to:

• Scheduling follow-up appointments

• Coordinating durable medical equipment (DME) and home health services

• Arranging transportation

• Completing insurance and financial paperwork

• Following up on post-emergency room and post-acute referrals

• Coordinating outpatient care services

• Providing resources for social determinants of health

• Delivering regulatory notices

Research has shown that leveraging non-licensed staff in discharge planning improves efficiency and allows licensed professionals to focus on clinical decision-making. By integrating this workforce, hospitals have significantly improved discharge times and reduced readmission rates (AHRQ, 2021).

The Adaptive Model recognizes the requirement for technology to enhance case management efficiency. Some of the key technological advancements now include automated workflows, telehealth and optimization of our electronic medical records. AI-driven case management software can help identify patients needing case management intervention earlier in their hospital stay (Garrett, 2024). Virtual discharge planning and follow-up visits improve post-discharge care coordination. Standardized documentation and decision-support tools improve communication among case management teams.

By leveraging these technologies, the role of case managers, whether nurses or social workers, becomes more focused on high-value clinical decision-making, while non-licensed staff and technology handle many of the administrative tasks. The model also shifts away from tenure as a measure of success, instead requiring a workforce with strong communication, technology and problem-solving skills to facilitate better interactions with medical teams, patients and outpatient providers.

Instead of adhering to traditional unit-based case management, the Adaptive Model acknowledges and prioritizes patients in the ED for early intervention to prevent unnecessary admissions and expedite appropriate discharges out of the emergency room. It also acknowledges the growing number of hospitalized outpatients, including surgical patients and those under observation. Case management in the Adaptive Model begins before the patient enters the hospital, with pre-operative assessments, education and planning.

Additionally, the Adaptive Model recognizes the increasing social complexity of patients. This has evolved from a singular social work function, to care teams equipped to handle these complexities through comprehensive, multidisciplinary approaches that adapt to the local community.

The traditional triad model of hospital case management is no longer sufficient in today’s fast-paced healthcare environment. The Adaptive Model provides flexibility to the local landscape and the transformative nature of healthcare. The model encompasses disciplines outside nurses and social workers as integral to the case management team such as non-licensed professionals, physician advisors and pre or post hospital case management roles. The Adaptive Model requires a new workforce with strong communication skills and technology acumen who can leverage the fast-paced technological advancements currently on the horizon in the case management space. Finally, the model expands the focus outside inpatients to encompass independent staffing structures for emergencies, pre-surgical, bedded outpatients and post-discharge outpatient settings. The Adaptive Model leans into the change for utilization review from one part of the three-legged stool to its own specialized set of professionals deeply tied to the clinical revenue cycle team members, thus shifting some of the requirements back to the case management team members. As healthcare continues to evolve, the Adaptive Model offers a pathway to a more efficient, patient-centered case management approach.

Case Management Corner: Avoiding Common Short-Stay Audit Pitfalls

By Kelly Bilodeau

Traditional Medicare short-stay inpatient stay audits help ensure appropriate patient status decisions and accurate billing. However, organizations commonly struggle to implement a compliant process and run afoul of Medicare regulations, said Sara Williams, MSN, RN, ACM-RN, vice president of clinical strategy at Phoenix.

“Many facilities I’ve visited lately have gaps in their Medicare short-stay audit process,” she said. Hospitals often allow nurses to make downgrade determinations for patient cases that don’t meet one of the Medicare exclusions for an inpatient stay that lasts less than two midnights. However, CMS regulations reserve this role for a physician member of the UR committee. “Other organizations weren’t notifying patients within 48 hours that their stay would be billed under their Part B benefit instead of Part A after a review found they didn’t qualify for an inpatient admission,” Williams said. “Most of the organizations weren’t notifying the patient at all. They were just making the change to Part B billing.”

Monitoring compliance

CMS expects facilities to classify patients accurately, and short-stay reviews are a simple way to verify that the patient’s status is correct.  “Medicare does audit these short stays,” Williams said. The annual Program for Evaluating Payment Patterns Electronic Report (PEPPER) provides valuable insights into an organization’s one-day stay trends, comparing them to national and state data. It also allows facilities to compare themselves against organizations in similar locations. So, facilities should familiarize themselves with the information contained in the report. 

CMS allows for short-stay exceptions, so a UR nurse may determine that a case meets inpatient criteria even if it falls short of the required two midnights. For example, the stay may qualify under an exclusion if the patient’s surgical procedure is on the inpatient-only list. Some other examples of exclusions include the following: 

·       The patient expired before the second midnight.

·       The patient was transferred to a higher level of care.

·       The patient transferred from another facility and has two medically necessary midnights combined between the two hospital stays.

·       The patient left the facility against medical advice.

·       The patient transitioned to hospice during an appropriate inpatient hospitalization.

However, if the case doesn’t meet a defined exclusion, a physician member of the UM committee must review it to make a final determination, Williams said. If the UM Committee physician determines the case doesn’t meet the requirements for Part A billing, they must notify the attending provider and give them a chance to weigh in. The attending can respond within a set time frame to affirm the change, or choose not to respond, which is also seen as an affirmation. In these cases, the hospital must self-deny the original Part A claim and rebill the claim under Part B. This change triggers a mandatory patient notification. “The letter that goes to the patient needs to be very succinct and explain the billing change because it can be confusing. I've seen patients call and say: I was in the hospital? Why are you saying that's not covered?’” Williams said.

However, if the attending physician disagrees with the UM Committee physician’s assessment, they can submit additional details and the case will move to a second review by another physician member of the UM Committee who makes the final determination.

Setting up supportive systems

Medicare short-stay review errors often occur because the staff responsible for the process aren’t given clear guidance, and due to confusion about the requirements outlined in the Medicare Utilization Review Conditions of Participation, Williams said. Providing additional education and tools for UR nurses and UM Committee physicians who carry out these reviews can often solve the problem.

Organizations should establish workflows to support the process, including communication channels with revenue cycle staff members to bill corrected claims accurately. “Leverage your EMR as much as you can to automate this process,” Williams said.

Although the Two-Midnight Rule went into effect more than a decade ago, organizations still struggle to understand the complexities of the short-stay review process. Proper documentation can help. Providers should clearly document why a two-midnight stay in the hospital is medically necessary for each inpatient. Avoid canned, check-box responses. “In addition, if the patient does get better more quickly than expected, there's very clear documentation on the back end to say that,” Williams said. “Sometimes you may anticipate that a patient is going to be hospitalized for two midnights or more, and they improve more quickly than expected,” Williams said.

Establishing a proactive process and coordination between UR and Revenue Cycle/Integrity departments can help ensure your organization gets it right.

Case Management Corner is your go-to source for insightful discussions on relevant topics in case management. Through an engaging interview-style format, our team members share their expertise, experiences, and best practices to keep you informed and empowered. Whether you're looking for industry updates, practical strategies, or real-world perspectives, we bring you valuable conversations designed to enhance your knowledge and support your professional growth. Stay tuned for expert insights straight from the field! Kelly Bilodeau has been a longtime writer for HCPro’s Case Management Monthly.

Could UnitedHealth Group’s Woes Ultimately Result in Improvements?

By Juliet Ugarte Hopkins, MD, ACPA-C

In the last seven months, UnitedHealth Group (UHG) has been racked by devastating events, from the massive cyberattack on Change Healthcare in October to the murder of UnitedHealthcare’s (UHC’s) CEO, Brian Thompson, in December. 

At the end of last month, after reporting a weaker-than-expected first quarter (despite posting $6.3 billion in profit during the same timeframe), UHG stock plummeted by more than 22 percent, faster than any drop seen by the company in the last 25 years. 

UHG’s CEO at the time, Andrew Witty, associated the poor performance with beneficiaries – especially those within their Medicare Advantage (MA) plans – utilizing more medical services than expected. This comment truly (and possibly, inadvertently) illustrated the point that health insurance companies make more money for their shareholders when their beneficiaries don’t seek out or receive healthcare services.

This comes as no surprise to case managers everywhere who try and secure skilled nursing facility (SNF) or inpatient rehabilitation facility (IRF) care for hospitalized patients and repetitively face stalling tactics (and ultimately, denials).

Then, on May 13, UHG stock dropped again, this time by more than 16 percent, in the hours after Witty abruptly resigned “for personal reasons.” Despite multiple lawsuits and threatened actions by private, state, and federal agencies across the country, UHG has been a longtime dominant force related to revenue cycle, provider staffing, utilization, and managed and commercial health insurance plans.

The owner of Aetna, CVS Health, as well as Humana have also seen recent declines in their profitability, but to a lesser extent than that of UHG. This is likely a reflection of what historically has served UHG so well in the past – a profound presence in healthcare across the country.

Last year alone, UHG acquired or created over 250 subsidiaries, including acute surgery centers, home care companies, and pharmacies. The thousands and thousands of new beneficiaries that came along with these subsidiaries – many of whom are covered by UHC’s managed Medicare plans – possibly led to the unanticipated increase in costs of medical services. 

On May 15, UHG stock plunged yet again, by more than 15 percent, after the Wall Street Journal reported the U.S. Department of Justice (DOJ) has been conducting a criminal investigation since last summer into possible Medicare fraud carried out by UHG’s Medicare Advantage arm of the business. This is in addition to a DOJ civil investigation announced at the start of the year, looking into the possibility of UHG inappropriately assigning more significant diagnoses to beneficiaries to obtain larger or extra payments from Medicare.

While an official announcement from the DOJ has not yet been made, considering that UHG stock is down almost 50 percent since the start of 2025 and has lost over $300 billion of its $600 billion market value in one month, it’s clear recent events have taken their toll on the company and are not a simple blip on the radar. Since the road toward the astronomical profitability UHG has enjoyed in prior years was paved with narrow medical care access for beneficiaries, what could these recent events mean for hospitals and the patients they serve? Increased scrutiny of the medical necessity of emergency department care or hospitalizations? Escalated denials related to out-of-hospital continuation of care at SNFs, access to home nursing and therapy services, or coverage of medications and durable medical equipment (DME)?

Unfortunately, it’s very possible that beneficiaries and the health systems serving them will experience most of these frustrations.

On the other hand, should hospitals dare to dream that positive changes are on the horizon, concerning their dealings with UHC? In an effort of good faith, might UHC throttle back their aggressive tactics, involving an overwhelm-and-overcome strategy related to denials, and put less emphasis on shareholder dividends and more on patient care? 

While a possibility, it appears less likely now, given that Witty was quickly replaced by former UHG CEO Stephen Hemsley, who ran the organization from 2006–2017. 

References:

1. What UnitedHealth’s Stock Drop Reveals About Medicare Advantage, N. Adam Brown, MD, MBA, MedPage Today, April 29, 2025 

2. UnitedHealth Group Reports Third Quarter 2024 Results, BusinessWire, October 15, 2024

3. UnitedHealthcare stock takes massive hit after earning forecast cut, Fox 9 KMSP and Associated Press, April 17, 2025

4. UnitedHealth Group stock tumbles; Andrew Witty steps down as group CEO, Martin Baccardax, The Street, May 13, 2025

5. UnitedHealth Group shares plunge 13% on report of DOJ probe into possible Medicare fraud, Annika Kim Constantino, CNBC, May 15, 2025

6. UnitedHealth Responds to Fraud Investigation Report: ‘Deeply Irresponsible’, Newsweek, May 15, 2025

Navigating the Two-Midnight Rule with Medicare Advantage

By Tiffany Ferguson, LMSW, CMAC, ACM

In its Contract Year 2026 Medicare Advantage and Part D Final Rule (CMS-4208-F), the Centers for Medicare & Medicaid Services (CMS) addressed ongoing confusion about how Medicare Advantage (MA) plans apply inpatient criteria, specifically the “two-midnight rule” and how this interacts with appeal processes through the Independent Review Entity (IRE).

Layered deep in the seventh provision to clarify terminology regarding inpatient level of care, which primarily surrounds clarification of concurrent status changes and notice requirements for MA plans to patients, you will find a question from a key commenter who raised concerns about the disconnect between the two-midnight presumption used in traditional Medicare and the flexibility afforded to MA plans in denying inpatient claims.

The concern focused on the patient experience: beneficiaries are often admitted under an inpatient order, only to learn later that their stay has been reclassified as outpatient or observation, despite receiving the same level of hospital care. This results in potential financial liability and confusion, particularly when coverage status changes mid-stay.

Despite the gains that many hospitals felt regarding MA final rule 4201, this appears to be an interesting clarification regarding the difference between the two-midnight presumption verse the two-midnight benchmark.

CMS clarified that while the rule strengthens various enrollee protections, it does not extend the two-midnight presumption to MA plans. The presumption, which deems inpatient admissions crossing two midnights as appropriate for Part A payment, was designed as a safeguard for traditional Medicare post-payment reviews conducted by Recovery Audit Contractors (RACs) or Quality Improvement Organizations (QIOs). The response then went on to say that this ruling is not a universal standard and does not bind MA organizations.

MA plans, however, are required to follow the inpatient admission criteria outlined in 42 CFR §412.3, commonly referred to as the “two-midnight benchmark.” This means that if a physician expects the patient to require hospital care spanning at least two midnights and formally admits the patient as such, the criteria for inpatient coverage may be met assuming the documentation supports medical necessity.

Importantly, CMS emphasized that if the IRE overturns an MA denial and determines that the inpatient admission meets criteria under §412.3, MA plans must honor the IRE’s decision and effectuate payment.

Although the two-midnight presumption remains outside the MA scope, CMS has taken other steps in the final rule to reduce patient and provider burden. These include stronger notice requirements for communication tools from MA plans to ensure level of care changes are communicated timely to patients, clarification on when MA beneficiary financial liability is triggered, and limitations on retroactive reclassification of previously approved inpatient stays.

To safeguard against the two-midnight benchmarking allowance for MA plans, the burden of proof will remain on providers to ensure thorough documentation surrounding intentions for admission, and the clinical rationale for inpatient care.

CMS Suspends Eight MIPS Improvement Activities for 2025

By Tiffany Ferguson, LMSW, CMAC, ACM

In early May, the Centers for Medicare & Medicaid Services (CMS) announced the suspension of eight improvement activities under the Merit-Based Incentive Payment System (MIPS) for the 2025 performance year.

The notice stated that “this decision aligns with the Improvement Activities Suspension Policy finalized in the CY 2021 Physician Fee Schedule (PFS) Final Rule (86 FR 65465),” and it can be seen as a precursor to their potential removal in future rulemaking.

MIPS, a key component of the CMS Quality Payment Program (QPP), requires eligible clinicians to report across four performance categories: quality, cost, promoting interoperability, and improvement activities. The improvement activities category specifically aims to encourage practice-level enhancements that support patient engagement, access to care, and population health.

For 2025, CMS is suspending the following eight activities:

1. IA_AHE_5: MIPS Eligible Clinician Leadership in Clinical Trials or Community-Based Participatory Research (CBPR);

2. IA_AHE_8: Create and Implement an Anti-Racism Plan;

3. IA_AHE_9: Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols;

4. IA_AHE_11: Create and Implement a Plan to Improve Care for LGBTQ+ Patients;

5. IA_AHE_12: Practice Improvements that Engage Community Resources to Address Drivers of Health;

6. IA_PM_6: Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities;

7. IA_ERP_3: COVID-19 Clinical Data Reporting with or without Clinical Trial; and

8. IA_PM_26: Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B.

While these activities are no longer available for selection in 2025, clinicians who have already completed or are in the process of completing them may still attest and receive credit. CMS has stated that all related QPP resources, including guides, factsheets, and the “Explore Measures and Activities” tool are currently being updated to reflect these suspensions. However, as of this report, nothing is available on the QPP website.

The rationale for these changes has not been elaborated on, but the move is expected to stir debate, particularly given that several of the suspended activities focus on health equity, social determinants of health (SDoH), and pandemic-related responses. CMS had previously emphasized these areas as high-priority in the wake of COVID-19 and ongoing efforts to reduce health disparities; however there is clearly a political shift in focus with the current administration.

Clinicians and practices participating in MIPS are advised to consult the updated 2025 Improvement Activities Inventory to identify alternative activities that align with their practice capabilities and patient population needs. The inventory remains a critical tool for guiding MIPS compliance and maximizing performance scores, which directly influence Medicare payment adjustments.

This suspension reflects an evolving policy landscape within CMS as the agency continues to balance an emphasis on regulatory burden reduction with the promotion of value-based care.

Per the news brief, additional updates and proposals are anticipated in future rulemaking cycles.

Leveraging the QIO for Patient-Level Appeals Under MA Final Rule

By Tiffany Ferguson, LMSW, CMAC, ACM

The finalized Medicare Advantage (MA) Rule 4208 includes important clarifications of enrollees’ rights to appeal denied inpatient stays. In my casual reading for clarification on another topic, I noticed this statement on page 175:

“We note that similar policies exist for other types of coverage denials. For example, after an MA organization determines that covered inpatient care is no longer necessary, the enrollee may file an expedited appeal of the discharge decision to the QIO (Quality Improvement Organization). If the QIO upholds the MA organization’s decision, and the enrollee has left the hospital, in accordance with § 422.622(g)(2), the enrollee may continue their appeal to the ALJ (administrative law judge), Departmental Appeals Board (DAB), and ultimately, Federal court (if other conditions are met).”

Specifically, under 42 CFR §422.622, MA enrollees may initiate an expedited appeal through the QIO when their plan determines that continued inpatient care is no longer necessary. This marks a critical shift in the landscape for hospitals and case management teams, especially as they grapple with increasingly aggressive denial practices from MA plans for continued stay hospitalizations – particularly for those untimely authorizations and post-acute denials. There have been increasing reports of MA organizations not only denying continued inpatient hospital days, but simultaneously delaying or denying authorizations for medically necessary post-acute care placements.

Traditionally, hospitals have issued the Important Message from Medicare (IMM) only in the parameters of the physician-expected and initiated discharge, in a similar construct to guidance for Medicare fee-for-service (FFS) beneficiaries. However, MA enrollees have distinct rights under §422.622 that differ from the FFS model. According to the regulation and operational guidance, once an MA organization issues a formal denial of continued hospital coverage, hospitals are responsible for informing patients of their right to request immediate QIO review, even if the patient remains hospitalized.

The guidance specifically states that “an enrollee has a right to request an immediate review by the QIO when an MA organization or hospital (acting directly or through its utilization committee), with physician concurrence, determines that inpatient care is no longer necessary.” Note that this statement does not cite all hospital care services, but specifically inpatient hospital services. 

Thus, the IMM should be provided alongside the MA plan’s denial notice, and case management/utilization review (CM/UR) teams should actively engage patients regarding their expedited appeal options. If the patient elects to appeal, they may contact the QIO directly, triggering an expedited review. Under section (c), the Centers for Medicare & Medicaid Services (CMS) confirms that the burden of proof is on the MA organization to prove to the QIO why the patient discharge is the correct decision, either on the basis of medical necessity or based on other Medicare coverage policies.

This process introduces several operational changes that CM/UR teams may want to consider. Once a notice of continued non-coverage is received from the MA plan, UM/CM teams will want to convene immediately, review with the attending for concurrence, and provide notice of denial to the patient with the IMM. This will notify the patient of their appeal rights to the QIO, and should the patient elect to appeal, the QIO would review to either support continued stay approval from the MA plan or push for timely authorization and support for needed post-acute placement.

By embedding the QIO appeal process earlier, when the denial is issued, rather than at discharge, hospitals can better protect patients, address financial inequalities regarding inpatient services, and challenge inappropriate payer behaviors that compromise safe discharge planning.

CMS Proposes Key Updates to TEAM Under IPPS Proposed Rule

By Tiffany Ferguson, LMSW, CMAC, ACM

In the FY 2026 Inpatient Prospective Payment System (IPPS) proposed rule, the Centers for Medicare & Medicaid Services (CMS) announced updates to the Transforming Episode Accountability Model (TEAM); discussed in prior articles, this is a new mandatory alternative payment model scheduled to start January 1, 2026. TEAM will run through December 31, 2030, and will test whether an episode-based payment approach tied to quality metrics can reduce Medicare expenditures while maintaining or improving care quality for beneficiaries.

TEAM will focus on five surgical episode categories: Coronary Artery Bypass Graft (CABG) surgery, lower extremity joint replacement, major bowel procedures, surgical hip/femur fractures, and spinal fusion. In the FY 2026 proposed rule, CMS has introduced several key modifications designed to adjust TEAM’s structure ahead of its performance start date. The changes include:

• Limited Deferment Period: Certain hospitals may be granted a temporary deferment from TEAM participation based on specific criteria such as new hospitals, purchased-acquired hospital, or data adjustments through the program period that would put a particular hospital in the program qualifying core-based statistical area.

• Track 2 Eligibility Alignment: Hospitals designated as Medicare Dependent Hospitals (MDH) will have participation eligibility linked to the expiration of the MDH program itself. Per the proposed ruling there are about 25 hospitals that are MDH and in TEAM.  21 of those are Track 2 eligible for being either a safety net, rural community, or sole community hospital.

• Finalized Quality Measures: The addition of the Information Transfer Patient Reported Outcome-based Performance Measure (Information Transfer PRO-PM) aims to strengthen patient-reported outcome tracking.

• Neutral Quality Measure Submission Option: TEAM participants who submit insufficient or low volumes of data will now receive a neutral quality measure score, proposed as essentially a score of 50 from 1-100, to avoid being penalized.

• Target Price Construction for Coding Changes: A recommendation has been proposed to adjust target pricing structures when procedural coding changes occur during the model period. CMS will also reconstruct the normalization factor and prospective trend factor used in financial benchmarks throughout the program period.

• Shift in Calculations: TEAM will replace the Area Deprivation Index (ADI) with the Community Deprivation Index (CDI) which is consistent with the ACO REACH model calculations.

• HCC lookback period: CMS proposes a similar adjustment to lessons learned from the bundled payment program to adjust the lookback period for Hierarchical Condition Codes (HCCs) to 180 days, instead of 90, with HCC v28.

• Removal of Health Equity: The updated ruling has removed any mandatory and voluntary data tracking and reporting for health-related social needs or health equity data.

• Adjustment of labels from gender to sex: For data reported, TEAMS participants will be required to submit the binary sex labels of surgical patients, rather than the previous term of gender.

• SNF 3-Day Waiver expanded to include swing beds: The ruling proposes including the SNF 3-day waiver for TEAM members to SNFs that meet the CMS Star rating requirements of 3 stars or better. The proposal noted that swing beds are being considered for this waiver, thus patients in TEAM will be eligible to transfer to a swing bed under the waiver program.

• Removal of the Decarbonization Initiative: CMS has also withdrawn the proposed Decarbonization and Resilience Initiative from the model.

Additionally, CMS is seeking public comment (but not proposing changes yet) regarding Indian Health Service (IHS) hospital outpatient episodes, low-volume hospitals, the use of standardized prices and reconciliation amounts, and primary care service referral requirements.

Through these updates, CMS aims to strengthen TEAM’s focus on driving quality improvement and cost reduction across surgical episodes. The proposed ruling describes these revised changes as a continued effort to promote fairness in performance assessment, and ensure a more seamless transition for hospitals into value-based payment models.

Hospitals impacted by TEAM should carefully review these proposed changes and consider submitting comments before the final rule is issued.

Understanding the First Steps To Address Custodial Hospitalizations

By Juliet Ugarte Hopkins, MD, ACPA-C

Custodial or social hospitalizations have been a long-standing issue within acute care hospitals. 

These patients generally arrive to the Emergency Department (ED) with vague or even no acute complaints. 

Following initial work-up, it’s clear they don’t medically require hospitalization but deficits in their day-to-day needs or the ability to care for themselves remain unsolved. As such, there is significant concern by the medical team and often, the patient themselves, that there is no safe path forward to ensure the patient’s well-being.

Some hospitals have Herculean initiatives and well-staffed teams focused on finding alternative modalities of care or placement out of the ED; but even they are unable to avoid hospitalization in every case. Every day, scores of patients across the country enter inpatient hospital beds for what amounts to custodial care. 

Assistance with ambulation, transfers, and activities of daily living (ADLs), administration of medications, and delivery of meals are all available in the hospital setting but don’t require the hospital to take place. Absent a perfect world with strong and all-encompassing support systems for these individuals who need assistance to safely live their lives, hospitals are the social safety net. 

Much has been written and discussed about this topic, including how to address or mitigate the problem. In fact, I and fellow MedLearn Media Talk Ten Tuesday panelist, Tiffany Ferguson, presented at the American College of Physician Advisors’ National Physician Advisor Conference recently about this very topic. But what often gets overlooked are the very first steps hospitals need to take when considering solutions. 

These initial steps seem incredibly simple but can be astonishingly complex, involving multiple teams to participate and ensure success – case identification and data collection.

In theoretical discussion, custodial cases seem easily identifiable. In reality, clarity wanes when medical staff are faced with providing care to dozens of patients over the course of a shift and are intimately aware of these patients’ profound limitations. 

Does that extremely debilitated, practically cachectic, 90-year-old man who hasn’t yet been able to take his medications without dropping a pill or two, really not need hospital care? What about the 42-year-old woman with severe developmental delays who was brought to the ED because her elderly parents simply can’t manage her transfers, toileting, and bathing any longer? 

What were the parents supposed to do?

Targeted discussion and education delivered to nurses, physicians, social workers, and case managers should focus on identifying the difference between no other available option to provide patient care, and care which can only be provided in the hospital. Emphasizing robust identification of these patients will allow the health system to effectively investigate augmentation of or collaboration with outpatient services and community support. 

Point out that when these patients are effectively cared for outside of the hospital setting, more hospital beds will be available for those who truly require them for their acute medical needs. 

Identification is one aspect, but collection of the data is another. Do you have modalities to capture different scenarios or discharge barriers in your electronic medical record? Who can enter this information, and is it simple for them to do so? 

If only case managers have this tracking tool access, how does the message get passed along when a nurse, social worker, or physician suspects a patient’s hospitalization is custodial in nature? Ultimately, who is reviewing the data and making sense of it all, providing recommendations of action? 

Patients who are hospitalized solely for custodial or social reasons should be classified as Outpatient or Outpatient in a Bed. They do not have need for Observation services, and their lack of need for care which can only take place in the hospital setting creates ineligibility for Inpatient status (regardless of how many days they are in a hospital bed before an outpatient care plan is established and the patient is discharged). 

However, what if a patient who is hospitalized for custodial reasons, then develops a condition which requires hospital care or investigation? In this instance, adding Observation services, at least, would be appropriate. But if your hospital’s method of identifying and tracking custodial cases involves designation of Outpatient status at discharge, these patients would be lost due to the addition of Observation services to the claim. 

This could be remedied by adding a different designator in your electronic health record which is independent of patient status and even allows tracking of days associated with cases which become custodial following a justified medical or surgical hospitalization. Since this is a situation to which case managers would be most attuned, application of this type of identifier by this team might make the most sense. 

However, they should not carry this mantle alone, which brings us back to education for physicians, bedside nurses, and others to participate in prompt identification.

Routine review of collected cases by a physician advisor should involve sorting into categorization types, payors, and length of time custodial care was provided. Categorization types might include the following:

1. Assistance with ADLs

2. Assistance with transfers/ambulation

3. Family no longer willing/able to care for patient

4. Facility no longer able to care for patient

5. Guardianship/other legal challenge

6. Unhoused

Collaboration with members of the hospital’s revenue cycle team can then assign a financial impact to these cases based on the cost of services provided without reimbursement. Additionally, retrospective review of the hospital’s ED boarding numbers and potentially lengthened throughput during days when there were high levels of custodial patients occupying hospital beds can provide more clarity to the overall impact of these cases to the hospital’s ability to function at its highest level for the surrounding community.

Support for development of comprehensive and effective processes will be realized only when the scope and impact of custodial hospitalizations is made clear to your hospital’s leadership. 

Before expending effort into how to address this issue, focus first on synthesizing a clear picture of the challenges and impacts.

Significant Changes to Medicare Readmission Reduction Program

By Tiffany Ferguson, LMSW, CMAC, ACM

In the FY 2026 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) proposed rule, the Centers for Medicare & Medicaid Services (CMS) introduced significant updates to the Hospital Readmissions Reduction Program (HRRP).

CMS is proposing five major changes to the HRRP that will have significant impact on how hospitals and health systems manage and address readmissions. If these proposed changes are finalized, important adjustments will be needed toward readmission avoidance strategies. 

The proposed changes include the following:

1. Inclusion of Medicare Advantage Data: Historically, HRRP has assessed readmission rates using data from only Medicare Fee-for-Service (FFS) beneficiaries. In a notable shift, CMS proposes to refine all six readmission measures to include patients enrolled in Medicare Advantage (MA). The IPPS ruling stated that this will provide a more comprehensive view of hospital performance across the full spectrum of Medicare beneficiaries and aligns with CMS’s broader goal of data harmonization.

2. Removal of COVID-19 Exclusions: CMS previously excluded patients with a COVID-19 diagnosis from the denominator of the readmission measures to account for pandemic-related disruptions. CMS now proposes to remove this exclusion across all six measures.

3. Shortening the Applicable Period: CMS proposes to reduce the applicable data collection period for readmission measures from three years to two years.

4. Revised DRG Payment Adjustment Formula: In conjunction with the inclusion of MA data, CMS proposes to modify the diagnosis-related group (DRG) payment ratios used in the HRRP payment adjustment formula. These modifications are intended to ensure the payment penalty calculations accurately reflect the expanded patient population and the varying costs associated with MA versus FFS enrollees.

5. Clarification of the Extraordinary Circumstances Exception (ECE) Policy: CMS seeks to update and codify the ECE policy, clarifying that the agency retains discretion to grant exceptions based on hospital-submitted requests. This adjustment (listed throughout the proposed ruling in many of the changes) aims to streamline administrative processes and increase transparency for hospitals impacted by extraordinary circumstances such as natural disasters or other systemic disruptions.

HRRP & MA Readmission Denials

There is a clear emerging tension between how hospital performance is measured under the HRRP in the proposed ruling and how MA plans are rated under the Medicare Star Ratings system. It appears that for now, hospitals are going to be caught with a potential double penalty, while MA plans appear unscathed.

As discussed in previous articles, under the current HEDIS data submission requirements, MA plans are not obligated to report all hospital readmissions. Because HEDIS measures rely on self-reported paid claims, MA plans are only required to submit data for readmissions they have approved for payment. Consequently, denied or bundled claims are excluded from the MA Star Rating calculations, potentially underrepresenting true readmission rate.

This creates a regulatory disconnect, as hospitals will now be held financially accountable for readmissions of MA patients as part of the HRRP.  Hospitals will also see no relief from the existing denials related to readmissions from MA plans. Thus, hospitals could be denied payment on a readmission from an MA plan and also have to report this as a readmission under the HRRP.  Yet the MA plans face no parallel accountability for these same readmissions.

While the FY 2026 IPPS proposed rule reflects a commitment to equal accountability across Medicare populations, true parity will remain elusive until CMS imposes comparable transparency and quality reporting requirements on MA plans.

As it stands, the burden of readmission accountability remains disproportionately shouldered by hospitals.

The Undoing of SDoH Reporting

By Tiffany Ferguson, LMSW, CMAC, ACM

In a sweeping policy shift, the Centers for Medicare & Medicaid Services (CMS) has proposed significant rollbacks to Social Determinants of Health (SDoH) and equity-related reporting requirements across the Inpatient Prospective Payment System (IPPS), Inpatient Rehabilitation Facility (IRF), and Long-Term Care Hospital (LTCH) settings.

Released April 11, drastic changes were introduced. Per the CMS email brief, the fiscal year (FY) 2026 proposed rules reflect the CMS alignment with Executive Order 14192, “Unleashing American Prosperity Through Deregulation,” which prioritizes the reduction of administrative burden and private-sector compliance costs.

Under the FY 2026 IPPS proposed rule, CMS has announced its intent to remove four key measures from the Hospital Inpatient Quality Reporting (IQR) Program beginning with the Calendar Year (CY) 2024 reporting period/FY 2026 payment determination:

1. Hospital Commitment to Health Equity – This was a structural measure to evaluate a hospital’s leadership, training, data collection, and community partnerships to advance health equity.

2. COVID-19 Vaccination Coverage Among Healthcare Personnel – This measure captured frontline worker vaccination rates and was considered a critical post-pandemic accountability tool.

3. Screening for Social Drivers of Health – Introduced to assess whether hospitals are actively identifying patient challenges related to housing, food, transportation, and utilities.

4. Screen Positive Rate for Social Drivers of Health – A complementary measure to quantify the proportion of patients screening positive for social needs.

The elimination of these measures marks a notable retreat from the CMS prior emphasis on collecting actionable data to address health disparities and improve care planning based on non-medical risk factors.

CMS is also proposing similar rollbacks in post-acute care settings through changes to the IRF and LTCH Quality Reporting Programs (QRPs), which currently require standardized data collection on patients’ social needs.

In IRFs, CMS proposes to eliminate four SDoH Standardized Patient Assessment Data Elements (SPADEs) from the IRF-Patient Assessment Instrument (PAI), effective in FY 2028. These include data fields for living situation, food, and utilities. These elements were designed to inform discharge planning and improve care coordination for medically and socially complex patients. Under the proposed ruling, however, these will no longer be required fields.

In LTCHs, CMS proposes parallel removals. Beginning in FY 2028, LTCHs will no longer be required to report living situation (R0310), the two items for Food (R0320A and R0320B), and the one item regarding utilities (R0330).

These proposed changes, while framed as efforts to reduce provider burden, represent a broader retreat from embedding SDoH and health equity into federal quality and payment programs. The argument listed in the FY 2025 IPPS ruling, discusses the burden of training, data collection, and patients’ answering these same questions across multiple healthcare facilities.  However, since FY 2026 was the payment determination period, it is unclear if any benefit will be awarded to all the health systems that have been actively collecting this data and have ingrained this into daily workflows. 

Instead of SDoH, CMS is requesting ‘Consideration for Future Years in the Hospital IQR program- request for information (RFI): Well-Being and Nutrition’.

CMS’s regulatory realignment signifies the growing tension between administrative simplification and the drive for more equitable, data-informed care delivery. At this time, it does not appear that the SDoH z-codes have been adjusted, however the link provided in the proposed ruling to review coding changes appears to not be working.

Although it is clear that hospitals and health systems did have increased burden with the SDoH questions, removal of these requirements does not eliminate the presence of SDoH risk factors and its impact on patient health outcomes.

Public comment is open regarding the proposed ruling.

How Can the Discharge Lounge Concept Work?

By Tiffany Ferguson, LMSW, CMAC, ACM

In a follow-up to last week’s article about when discharge lounges do not work, I thought I would elaborate today on when the concept can provide efficient relief for capacity issues.

Although the focus has historically been on the back-end process, moving patients out of their hospital rooms to alleviate congestion at the front, there is evidence supporting their effectiveness when discharge lounges assist not only hospital units, but also emergency departments (ED), and operate by a “pull” system rather than a “push” system.

ED overcrowding remains a significant challenge for hospitals across the country, leading to prolonged patient wait times, decreased patient satisfaction, and increased strain on medical staff. Implementing discharge lounges for patients who are stabilized but need to wrap up the logistics of returning home has proven effective in enhancing patient flow and alleviating ED congestion.

In a “push” system, hospital units or ED staff send patients to the discharge lounge when they deem them ready, based on a long list of eligibility criteria. This can lead to inefficiencies and underutilization. In contrast, a “pull” system actively identifies and relocates patients who meet discharge criteria, optimizing patient movement and improving throughput.

Hospitals that have successfully implemented a pull system employ dedicated discharge teams that proactively seek out patients eligible for discharge, ensuring a steady flow of patients to the lounge. These teams coordinate with unit nurses, physicians, and case managers to identify and transition patients efficiently. This approach prevents bottlenecks in the ED and bedded units, ensuring that beds are available for incoming patients who require immediate care.

Case Examples

Montefiore Health System implemented a discharge lounge that serves approximately 678 patients per month, or about 22 patients per day. Montefiore reports that their discharge lounge is six times more effective than other lounges, largely due to its role in serving both hospital units and the emergency department. Their system moves patients efficiently by proactively pulling them from bedded units and the ED, rather than waiting for units to push patients to the lounge (Montefiore, 2024).

The University of Alabama at Birmingham (UAB) Hospital has also refined its discharge lounge operations over time. Initially, it accommodated only four patients a day, but by 2022, it averaged 20 patients daily. The key to this improvement was a dedicated discharge team that actively pulled patients from the units, ensuring a smooth transition to the lounge and reducing overall hospital congestion.

Repurposing discharge lounges to support ED throughput and create a better environment for patients who have completed their ED evaluation, but require additional logistics such as obtaining medications, follow-up referrals, education, support appointments, or coordinating transportation can significantly alleviate ED congestion. A pull system ensures that discharge-ready patients are efficiently relocated, freeing up critical ED and inpatient resources. By focusing on active patient identification and proactive support to facilitate the discharge process, hospitals can optimize resource utilization, improve patient experiences, and enhance overall operational efficiency.

References

Montefiore Einstein (2024). Montefiore Discharge Lounge Offers Stress- Free Transition from Hospital to Home While Saving 10,000+ Bed Hours. Retrieved from Montefiore Discharge Lounge Offers Stress-Free Transition from Hospital to Home While Saving 10,000+ Bed Hours | Update | Montefiore Einstein Now

UAB Medicine News (2022) Nursing leaders created patient discharge lounge to reduce ED boarding time. Retrieved from Nursing leaders create patient discharge lounge to reduce ED boarding time