Strategies for Creating a Valuable Utilization Review Committee
The federal statute 42 CFR § 482.30, in the Conditions of Participation for Utilization Review (CoP), requires that each hospital must have in effect a utilization review (UR) plan and a utilization review committee (URC). The CoP lists specifications regarding committee requirements; however, it is left up to the hospitals to decide how functional these committees will be.
Written By Tiffany Ferguson, LMSW, CMAC, ACM, and Ryan Greiner, MD
The federal statute 42 CFR § 482.30, in the Conditions of Participation for Utilization Review (CoP), requires that each hospital must have in effect a utilization review (UR) plan and a utilization review committee (URC). The CoP lists specifications regarding committee requirements; however, it is left up to the hospitals to decide how functional these committees will be.
Utilization Management versus Utilization Review
Utilization management (UM) is encompassed by processes and workflows put in place by hospital leadership to contain costs, improve operating efficiency, and enhance use of hospital resources. UR is a subset of UM, and refers to the tools and methodologies that hospitals and payors use to ensure that the appropriate level of care in the hospital is achieved for patients.
Regardless of what each hospital calls its UR committee (URC or UMC), the functions within this committee should address topics related to the utilization management of the hospital, and should be clearly stated in their UR plan. Utilization review will involve the day-to-day activities of UR specialists and physician advisors. These specialists will likely overlap with the URC, and will be called upon during the day to address requirements for Medicare and Medicaid beneficiaries, such as discharge appeals and Condition Code 44s. The aggregated data, plus more, will be discussed as part of the URC, as it applies to the UM strategy for the hospital.
Meeting the Minimum Expectations
URC must consist of two or more practitioners who carry out the UR function for the hospital. They typically include leadership in UR and/or case management. In addition, there must be two members of the committee who are physicians, ideally directly impacted or involved with the UM interests of the organization. Typical individuals who fulfill this role are a hospital’s physician advisor, chief medical officer, medical director for hospitalist, and/or medical director for emergency physicians. The goal is to ensure that the members of the committee are interested and invested in the topics discussed, and can leverage other key stakeholders in the hospital, especially when reporting URC meeting updates to the medical executive committee. These two physicians must be part of the medical staff; however, there is no requirement that they be employed by the hospital.
It is also important to note that although the committee will be reviewing physician and departmental data and utilization practices, the committee holds no direct authority regarding performance issues. During a hospital survey by its accrediting body or during state review, the hospital will be expected to furnish their UR plan, UR committee meeting minutes, sample presentations, and evidence of meeting attendance, as well as follow-up actions to the topics discussed. The surveyors will be looking for congruency from what is in the plan to what is discussed in the URC (and acted upon in the committee). Surveyors will typically expect the URC to meet on at least a quarterly basis. The scope of CoP 482.30 defines that the URC is responsible for the management and review of hospital resources, including admission status, continued or outlier patient stays, and use of professional resources, so these items will need to be addressed specifically.
Making the Committee Meaningful
What the rules do not say:
Who else is included in the URC as committee members. Such members could be leadership from nursing, surgery, emergency, bed placement, clinical documentation integrity (CDI), health information management (HIM), financial analysis, denials and appeals, revenue cycle, lab, pharmacy, and/or physical therapy.
What the topics discussed by the committee will be. The goal of the committee is to evaluate resource utilization of the organization. Examples are given regarding blood product usage and antimicrobial stewardship; however, the committee could also be reviewing such items as hospital deferrals, medical supply wastes, or unnecessary surgery cancellations.
How frequently the committee can choose to meet, and if the committee would want to have subcommittees, such as connecting the URC directly with a denials committee or patient complex case reviews (which could be optimal).
Why topics are presented, and what format they are given. Engaging your audience means avoiding death by PowerPoint. Consider asking the leaders involved in the work to provide slides, and ensure that the slides are easy to understand and involve questions and topics for committee discussion.
Consider reviewing with hospital leadership/c-suite the top priorities of the organization regarding resource utilization, and see how those can be addressed through the committee either directly or as a subcommittee that will report its findings. This will allow for greater c-suite engagement – and potentially more physician engagement. This will also ensure that these issues do not fall to another area, where leadership is forced to have “yet another meeting,” when it could all flow through the URC (the meeting that is required).
Topics to consider:
Observation rate and length of stay (LOS; likely just the topic that will get the CFO to sit in and see what’s happening);
Trends of concurrent and retroactive denials;
Hospital diversions and ED holds;
Canceled surgeries due to lack of authorization;
Throughput: progression of care delays;
Outlier case reviews of extended stays and high costs (consider as a weekly subcommittee);
Review of the Program for Evaluating Payment Patterns Electronic Report (PEPPER), which can be useful as it pertains to discussing outliers, and may give the team additional areas to focus on for improvement. If you don’t receive this, you can find information at https://pepper.cbrpepper.org/;
Overutilization of services: imaging, lab, therapy;
Antimicrobial stewardship/pharmacy;
Avoidable day reports and action steps;
Value-based metrics and hospital performance related to costs of care;
Compliance concerns related to audits; and
HIM, coding, and CDI performance.
Sample UR Committee
Given the potentially broad scope of work inherent to modern UM, the minimum requirements for the URC are arguably insufficient to address evolving healthcare system needs. Health systems are increasingly charged with ensuring the provision of value-based care, appropriate use of healthcare resources, and standardization of evidence-based treatments, while also maintaining revenue and compliance integrity. Healthcare customers are increasingly cost- and insurance-savvy, with expectations that their healthcare providers be effective custodians of their insurance benefits and bank accounts. As such, the traditional URC alone is just not enough in today’s complex healthcare ecosystem.
The regulatory and survey requirements for the URC are established, and the rules still need to be followed to the letter. However, structuring a modern and effective UM program dictates the need for a more robust arrangement of multiple committees that report their activities and outcomes to the URC. One approach, adopted at North Memorial Health Hospital in Robbinsdale, Minnesota, utilizes multiple committees charged with various aspects of URC requirements and effective UM practices. This approach has been an effective way to produce optimal outcomes. The following is a visual representation of that approach, followed by the descriptions and charges of those committees:
URC:
The committee charged with the traditional mandated activities, as outlined in the minimum requirements, with the addition of functioning as a steering committee for subcommittees. The URC can report through various leadership structures, including medical executive, quality, and clinical leadership.
Denials Prevention and Management (DPAM):
Primarily adjudicates contracted plan denials, including Medicare Advantage (MA) plans. This committee ensures that there is no single decision-making on self-denial or the decision not to appeal a case. If not overturned, all failed peer-to-peer cases are reviewed for decision on post-bill appeal. If the decision is to self-deny or accept denial, reason for acceptance is documented for reporting, trending, and tracking. This is an excellent venue for physician advisor and UM/RN education, led by the denials management RN coordinator.
Readmission Prevention and Management (RPAM):
Addresses unique treatment plans for high-utilizers, reviews avoidable readmissions for quality improvement initiatives, and addresses readmission denials for potential appeal. It is led by the CM manager and supervisor.
Avoidable Nights Prevention and Management (APAM):
Reviews avoidable night reports, identifies trends, and establishes quality improvement initiatives that can be assigned to appropriate hospital committees for additional work. It is led by the UM manager.
Acute Care Medicine/Clinical Leadership Council (ACM/CLC):
Multidisciplinary committee that develops, implements, and tracks evidence-based clinical care pathways. It is resourced with data analysts, IT/EHR experts, provider champions, nursing, and other key stakeholders, and is led by the medical director for quality.
Standing members are part of all committees, including UM/CM RNs, UM/CM leadership, physician advisors, and the medical director for UM/CM. In addition, based on the committee charter and responsibilities, revenue cycle, clinical, and quality team members are assigned as permanent members. Interested members of the medical staff are also invited to participate.
Structuring the innumerable responsibilities of URC into subcommittees can allow for more effective outcomes by targeted participation of busy team members and leaders and the creation of multiple pathways to achieve optimal outcomes for patients and the health system. URCs do not need to be perfunctory meetings that only exist because they are mandated by the Centers for Medicare & Medicaid Services (CMS). They can be optimally designed to run and operate via creative means to manage and improve the usage of hospital and patient resources.
References:
Daniels S. & Hirsch R. (2021) The Hospital Guide to Contemporary Utilization Review, Third Edition. HCPro, Brentwood, TN.
Update: What Case Managers Need to Know About the 3 Day Rule for SNF Stays
The COVID 19 Public Health Emergency (PHE) is expected to end on May 11, 2023. When this occurs the waiver for the Qualifying Hospital Stay (3-Day Stay) will end as well.
This article is in collaboration with the Center for Case Management.
Written By Tiffany Ferguson, LMSW, CMAC, ACM, and Melissa Ward, MSN, BSN, RN
The COVID-19 Public Health Emergency (PHE) is scheduled to end on May 11, 2023.
When this occurs, the waiver for the Qualifying Hospital Stay (3-Day Stay) also ends—reinstating the 3-day inpatient requirement to qualify for Medicare A coverage of a Skilled Nursing Facility (SNF).
The 3-day stay is based on the time of the order for inpatient; the patient must pass three midnights of continued, medically necessary inpatient hospital care to qualify for skilled nursing placement.
Case managers need to resume tracking their Traditional Medicare patients if identified as potential skilled nursing placement. We caution relying on the SNF to authorize the stay as they may not know the exact date and time of the inpatient order.
Things to consider as this rule is reinstated:
This is a CMS rule for traditional Medicare patients.
Medicare Advantage (MA) plan has specifications in their contract and provider manual that may allow the transfer of patients to skilled placement regardless of the 3-day rule or even the requirement of inpatient admission.
Case managers should also be aware of the 30-day and 60-day benefit periods that apply to the qualification of the 3-day stay.
Patients who have a break in skilled care that lasts more than 30 days will need a new 3-day hospital stay to qualify for additional SNF care
The new hospital stay doesn’t need to be in the same condition that they were treated for during the previous stay
For patients that do not have a 30-day break in skilled care, then the 3-day stay rule does not apply
As a reminder, patients with high utilization of SNF placement must be out of acute care for 60-days for their benefits to restart. There can be a significant financial impact to those patients that lose this coverage.
Case managers need to stay informed on any changes or updates related to the COVID-19 PHE and its impact on healthcare services. As the situation evolves, new information or changes that affect patient care and case management processes may become available.
Key Takeaways:
The 3-day inpatient requirement to qualify for Medicare A coverage of a Skilled Nursing Facility (SNF) will be reinstated due to the end of the Public Health Emergency which is scheduled to end on May 11, 2023
Case managers need to resume tracking their Traditional Medicare patients if identified as potential skilled nursing placement.
The 3-day rule for inpatient stay applies to traditional Medicare patients. Medicare Advantage plans are not required to follow.
Ensure awareness of the 30-day and 60-day benefit periods that apply to the qualification of the 3-day stay as financial impact to the patient if requirements are not met.
Partnership with Utilization Management is vital to minimizing the risk of denials or reimbursement delays.
Useful Tips:
Develop a tip sheet for new providers who were not in practice when the rules changed or not aware that rules are returning.
Present this information at your UR committee meeting and service line meetings.
Collaborate with your UR team who may understand the payer rules related to these changes.
Consider patient/family education regarding these changes.
Work with your emergency room case management team to ensure they are addressing alternatives for patients with potential avoidable admissions or within the 60-day window.
What Case Managers Need to Know About the 3 Day Rule for SNF Stays
The end of the public health emergency (PHE) brings new challenges regarding the old Three-Day rule.
This article appeared on RACmonitor.com on April 27, 2023
The end of the public health emergency (PHE) brings new challenges regarding the old Three-Day rule.
The three-day stay for Medicare patients is the requirement that based on the time of the order for inpatient, the patient must pass three midnights of continued inpatient hospital care to qualify for skilled nursing placement.
The reminder of this rule is important for many case managers as we have had a break for the last two years from counting midnights. This will be one more thing that case managers will need to make sure they are tracking when it comes time to transfer qualifying Medicare patients to skilled nursing facilities. The two-day rule for inpatient stay specifically applies to traditional Medicare patients, patients that have a Medicare Advantage (MA) plan have specifications in their contract and provider manual that may allow the transfer of patients to skilled placement regardless of the three-day rule or even the requirement of inpatient admission.
Case managers will want to check their hospital contracts and verify during the skilled nursing authorization period if the contracted payer will once again make this a requirement. I would expect the hospital case management team to be up to date on this expectation as one cannot rely on the skilled nursing facility (SNF) to know the exact date and time of the inpatient order. However, similar to before the PHE, it was a common occurrence for case managers to submit a copy of the inpatient order when sending clinicals to the post-acute facility to verify the inpatient admission date and time.
There are some additional specifications to the rule that is important to remember. The qualification of the three-day stay surrounds two calendar periods— a 30-day period and a 60-day period of benefits.
The 30-day period states that if a patient has a break in skilled care that lasts more than 30 days, they will need a new three-day hospital stay to qualify for additional SNF care. The new hospital stay doesn’t need to be in the same condition that they were treated for during the previous stay.
For patients that do not have a 30-day break in skilled care, then the three-day stay rule does not apply. For example, a patient was inpatient on the index admission for four inpatient hospital days, the patient was recommended for SNF, but elected to go home with home health instead. The patient went home for two days and realized this was a terrible idea and returned to the hospital. The patient was readmitted as outpatient with observation services and recommended again for SNF placement. The patient would still be eligible for SNF placement because they completed a qualifying inpatient hospitalization during their index admission, and it was within the 30-day period.
Patients that go to SNF must also have a 60-day break from utilization in order for their SNF benefits to renew. This means that a patient that was in the hospital and then spent 24 days in the SNF, then returned the next week to the hospital and then needed to discharge to skilled again, would not renew their benefits. They would go straight into the continuation of the previous benefit period which would be the patient’s coinsurance days 21-100, this could be up to $200/day unless the patient has a secondary to help cover the cost.
In summary, case managers will need to remember the following-
With the end of the PHE, the three-day rule for SNF placement as returned for traditional Medicare patients. Meaning patients will need a three midnight stay from the time of the inpatient order in the hospital to qualify for SNF placement if medically necessary.
Patients who have had a qualifying hospitalization within a 30-day period and return to the hospital for either emergency or observation services can still transfer to SNF if medically appropriate without having another three-day inpatient stay.
This rule may not apply to MA, Medicaid, or commercial plans, this will be up to the payer contract and provider manual.
Patients with high utilization of SNF placement must be out of acute care for 60-days for their benefits to restart otherwise their SNF stay will resume at the previous benefit day count of coverage.
Programming note: Listen to Tiffany Ferguson’s live reporting on the social determinants of health (SDoH) every Tuesday, 10 Eastern, on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.
Understanding Inevitable Unavoidable Delays
Delays in transitions to post-acute care are a vexing issue.
This article appeared on ICD10monitor.com on March 27, 2023
Delays in transitions to post-acute care are a vexing issue.
I am continuing to see a significant number of healthcare organizations dealing with denials and delays related to transitions to post-acute care. As such, I thought it would make a good topic for today’s article.
Delays related to transfers to post-acute facilities such as long-term acute care (LTAC), rehabilitation centers, or skilled nursing facilities (SNFs) are common across the country, and there are a couple of factors at play:
There is an internal hospital issue with over-referring to post-acute facilities;
Payors have intensified their review process prior to sending patients to post-acute care, as noted in an increase in delays, denials, and appeals; and
There continues to be limited staffing in post-acute facilities, causing a bed crunch.
In review of one of our client’s avoidable days, we are seeing these issues delay patients’ transfers to the tune of anywhere from 2-7 days, as they await placement in a post-acute facility and deal with their insurance company.
During the COVID-19 pandemic, hospitals were encouraged to send patients to other levels of care. The Public Health Emergency (PHE) waivers allowed hospitals to quickly move patients to post-acute facilities without prior authorization or the three-day inpatient stay requirement, in order to increase bed capacity. The trend was and unfortunately still is the mindset that “they no longer need to be here, so let’s free up a bed and move them to LTAC, rehab, or SNF.”
The payers do not practice this way; they are not concerned with your bed capacity issues. Since 2022, many payers started following post-acute InterQual criteria to authorize transfers to post-acute care, and any patients who did not meet the criteria were denied or required a peer-to-peer encounter. What payers are looking for specifically is, “why can’t the patient go home?” Then they will consider the next level up, or ask “why can’t this person have home health?” Then they will consider the next level. Reviewing physical and occupational therapy (PT/OT) documentation, their notes will make an optimal suggestion, but fail to consider why this could not have been in a lower care setting. For instance, yes, it would be great if every patient went to rehab, but that is expensive, and not always needed.
This is where case management comes in! A solid case management team should be able to work with PT/OT personnel, the physician, and care team, then make collective recommendations based on the assessment of the patient’s situation and the insurance factors proactively. However, case management has struggled as well over the last few years with turnover, short staffing, outdated models of practice, and lack of training (or, most likely, all the above). Many case managers are likely just facilitating the recommendations as they receive them and are unsure of what they can push back on. When this happens, the limited post-acute beds are being filled with patients who could have gone home, causing the hospital to hold patients longer because those patients who need the bed are stuck in the hospital waiting for transfer.
Yes, there is technology for efficiencies and guidance, but this is also indicative of a change of practice that is needed to unravel some of what was our best method – and became habit during the pandemic years.
Is your hospital or health system dealing with patients being denied transfers to post-acute facilities?
How Case Management Can Adapt to Our New Reality
What has UR lost being removed from the hospital setting?
This article appeared on CMSA.org on March 23, 2023
During the past three years, case managers have remained in the hospital as integral members of the healthcare team. As bed shortages were discussed on the news, at all hours of the day, case managers were working to develop safe transitions of care for patients to alleviate the burden. Case management, at all levels, has been involved in hospital meetings and conversations related to bed management and throughput. We supported each other and worked together through the storm. Nursing and healthcare are a community, and we have the mentality to stick together through tough times. But now, almost three years out, we are seeing case managers leave the hospital setting. Where are they going? Well, one place that I have witnessed them moving to, in BIG numbers, is remote UR positions. My company offers UR classes and in our most recent class, we had a high percentage of nurses who have left CM and have moved into new UR positions. They come to learn the essentials of UR for this new role. The UR positions are typically remote and give individuals the flexibility to work from home whereas most case management positions are still required to work in the hospital setting.
What has UR lost being removed from the hospital setting?
I am going to be a little nostalgic and maybe date myself, but I miss the days of sitting in the case management office, near the nursing unit, with my UR specialist in the same office. Their input and expertise on the patients’ status and criteria for possible SNF placement were helpful in the care planning of the patients. Their presence at the daily rounds, at the table with PT, CM and the physicians added value to the conversation. They would call out patients who were in observation and discuss patients who were approaching their expected length of stay or approved and denied days and expand the conversation to ready each patient for discharge. With the loss of UR at the table and recently in the hospital setting, these conversations now need to be discussed and led by the case manager. With those changes, I don’t believe these conversations are occurring as regularly during rounds. The loss of UR interaction on a daily basis with all members of the healthcare team has become diluted and hospitals have lost aspects of these critical conversations that advance the patients’ progression of care.
One of the most impactful changes related to the removal of onsite UR specialists is the loss of personal relationships with staff and physicians. UR specialists who have moved into remote positions in the past three years have likely never met their CM counterpart and may not fully understand their role. Physicians also only know the UR nurse by a phone call or through epic chat with conversations on status conversions. That personal connection that used to exist has changed and we must ensure that we have guideposts in place to not lose sight of the importance of connection.
In many organizations, UR specialists have also been pulled from the ED, which decreases and may eliminate the possibility of discussing admission status and options to discharge an inappropriate admission from the ED. UR specialists are now waiting to look for an admission order to review a patient rather than be proactive prior to the admission. Without the proactive approach to reviewing patients prior to an admit order, inappropriate admissions will make their way into hospital beds.
Now how do we move forward in increasing communication with technology?
How do we move forward and maximize communication with our current reality? How can we use technology to our advantage in the growing remote environment? Let’s bring UR back into rounds to participate and be included in all advantageous meetings through virtual invites. Each meeting could be set up with remote access and inclusion. The use of the electronic medical record chat has expanded conversations between the multidisciplinary team and can bridge the gap and communication with physicians. Increased visibility of UR continues to increase the awareness of their value to the organization. The support of an onsite physician advisor increases education and conversations with hospitalists and other team members related to utilization review and denials prevention. UR leaders need to acknowledge that AI and outsourcing of UR continue to creep into our world. It needs to be our priority to demonstrate the UR specialists’ contributions to our organizations. Step up and be seen throughout your organizations, showing the value that we deliver!
Bio: Marie is the Chief Operating Officer of Phoenix Medical Management, Inc., the leading case management firm. Marie has practiced as a nurse for the past 25 years with 17 years in the field of case management. Marie has served in several roles in Senior Leadership roles in Case Management. She has had leadership oversight including case management, utilization review, denials prevention, clinical documentation improvement, and medical record integrity. Marie has authored articles for RACmonitor, CMSA, and Case Management monthly. She is also a weekly contributor on Finally Friday and is a Board Member for the Arizona ACMA. Marie holds an MBA from the University of Phoenix and an MSN in Leadership from Grand Canyon University. She received her Bachelor of Science in Nursing from Northern Arizona University.
Knowing When and How to Fight the Good Fight
The need for benchmarking denials is evident as there are variations in hospital appeal processes.
This article appeared on ICD10monitor.com on March 20, 2023
The need for benchmarking denials is evident as there are variations in hospital appeal processes.
The c-suites of hospital organizations are often in a quest to benchmark their data against other health systems to see if a particular area is a legitimate concern, particularly when it comes to financial metrics such as denials.
Although it bears noting that such benchmarks are based on the specific organization’s set of reporting definitions, which can vary by internal practices and definition interpretations. The Healthcare Financial Management Association (HFMA) Claim Integrity Task Force has made significant strides to address this variation by providing standardized definitions and calculations for denials.
Despite such standard definitions, variation often still resides in the decisions made among the frontline employees, creating subjectivity for what is defined as a true denial. One often problematic area is the internal discrepancies in how a denial is categorized, and another is decisions made by appeal representatives when they decide what should be written off, how things are categorized, and what should be appealed.
When the business office receives notification of a denial, it typically comes in one of two ways; one is a remittance code provided on the returned claim. The remittance code is selected either automatically by the payer’s system, or it is entered manually by someone on the payer side, depending on the code and the sophistications of their technology. Once the claim is returned to the billing office, they will review it and see if this was a kickback because of an error, meaning that the claim went out with something missing that requires simple correction, or if the claim is being partially or fully denied. At that point, either the biller or technology within the billing software will correct the error and resubmit. If they are unable to do this, they will review the claim and make a decision internally on what should be adjusted as contractual, or if this is a denial. In concert with this process, if the claim is being denied, the payer will also send a letter with justification for the denial. This letter and the confirmed lack of payment then is managed by an appeal representative.
APPEALING THE DENIAL
Again, this practice is also widely variable across healthcare organizations because of hospital size, denial team structure, and if the denial and appeal work is completed internally, outsourced, or a hybrid. When the denial is reviewed by the appeal individual/ team, there is also another decision point. The hospitals all take variable approaches at this point, asking themselves how many denials they will fight, and up to which level? What dollar amounts are worth fighting for, and when should the denial be written off? Based on all these variables, CFOs looking for benchmarking should really understand their internal processes and definitions before they question their denial performance in the marketplace.
AHDAM RECOMMENDATION
The Association of Healthcare Denial and Appeal Management (AHDAM) has a great process for evaluating denials. This process involves a simple question: “What is the likelihood of overturning this denial on appeal?” They recommend an internal tracking mechanism called an “appealability score.” Although the tool is slightly subjective, what it forces the appealer to say is, “based on the review of this case, guidelines for evaluation, and the documentation, what is the likelihood that this denial will be overturned if I appeal?” By asking this question and applying a score, denials are placed in two categories: internal opportunities for the organization, and external opportunities with the payer. This score is then documented on each review and tracked in the denial metrics data against key performance indicators (KPIs).
For example, by applying this mechanism, cases that were still denied by the payer that nonetheless have a high appealability (winnability) score could then be aggregated, providing a justifiable case to discuss in payer-hospital joint meetings, or even to submit it for arbitration. Appealability score criteria should be made as neutral as possible so that fair comparisons can be made among payers.
Organizations that apply an appealability score will likely have a higher win rate on their appeals because they internally made a decision on what they knew was worth fighting for. This is compared to other hospitals that have decided to fight everything, knowing full well that they will not win them all. The concern with this effort is the number of internal people and amount of time it takes to fight claims when the payer was likely justified for not paying the hospital (and it lacks an opportunity to create an internal structure for denial prevention). If the healthcare organization instead decides to identify their “low-appealability” cases for internal review, they can subcategorize these by accountability owners and reasons to create improved processes to prevent the denials from even occurring in the first place.
New SDoH Report Reveals Smoking, Drug, Alcohol Utilization History
AHIMA makes policy recommendations for SDoH.
This article appeared on RACmonitor.com on March 13, 2023.
AHIMA makes policy recommendations for SDoH.
Last month the American Health Information Management Association (AHIMA), in partnership with the National Opinion Research Center (NORC) at the University of Chicago, released their final report on Social Determinants of Health (SDoH) Data. The survey was completed with a little more than 2,600 respondents to obtain a better understanding of how SDoH information is collected, coded, and used to inform the development of potential educational tools and resources that may be needed for health information professionals, as well as guidance for policy recommendations.
The report found that about 78 percent of respondents confirmed that their organization is collecting SDoH data primarily through electronic means, typically through the electronic medical record (EMR). Regarding the most prevalent SDoH domains, it appeared that collecting information for health and health behaviors was the highest priority among healthcare organizations. Examples of this information include health insurance coverage and health factors such as smoking history and drug or alcohol utilization. One can understand why this is easily collected data, as any service requires registration of health insurance/coverage benefits, and tobacco and substance use history is a standard in nursing and physician documentation.
The second-most common factor was housing insecurity, followed by economic insecurity. However, after that it was really a grab bag of other SDoH factors in the rankings.
One of the policy recommendations from AHIMA was to create standardized, clinically valid, and actionable data elements for collection. I would strongly request that organizations follow the Centers for Medicare & Medicaid Services (CMS) social drivers of health, which at this time has prioritized housing, food, utility, transportation insecurity, and personal safety as the top issues.
However, I would absolutely agree with AHIMA that CMS’s quality metrics should be used in concert with the push for CMS’s SDoH z-code capture.
Additionally, the report found that although the majority of respondents are consistently using ICD-10-CM for coding and collecting SDoH data, the tools that are utilized to screen and assess members are widely different. There was also a significant decline in the integration of this information into workflows after the data was collected. Obviously, the challenges inherent in this discrepancy were cited as being related to lack of training in how to find these details in the medical record (and then what to do with it once it has been collected). The limitations are likely tied to AHIMA’s second policy recommendation, which is the request for CMS to align financial incentives with these efforts around SDoH.
I would absolutely agree with this request, as the amount of work needed to care for patients that struggle with such SDoH factors as housing insecurity significantly impacts the resources and amount of care medically needed for this population. Recognition of these efforts beyond internal data collection would absolutely go a long way.
Programming note: Listen to live reports on SDoH with Tiffany Ferguson Tuesdays on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer, 10 Eastern.
Resource:
Driving Home the Need for Discharge Transportation
Coordinating efforts in the electronic medical record (EMR) and across disciplines are keys to tackling the social determinants of health (SDoH) – and specifically, transportation.
This article appeared on RACmonitor.com on February 27, 2023
Coordinating efforts in the electronic medical record (EMR) and across disciplines are keys to tackling the social determinants of health (SDoH) – and specifically, transportation.
Discharge delays related to transportation, whether avoidable or not, are a common occurrence for hospitalized patients. Some patients may have been transported great distances to a regional hospital, and now they need to return home, or they are being discharged to an alternative location and need transportation support to get to a post-acute location. Sometimes it is simply a delay because they do not have anyone to pick them up from the hospital, or they do not have a car that happens to be in the parking lot to drive themselves home after an emergency-room visit, procedure, or hospitalization. When appropriate, conversations with the patient and/or representative about potential discharge transportation needs should occur early in the hospitalization. In fact, a proactive approach would be to incorporate this as protocol.
As we approach the social drivers of health requirements, hospital personnel are required to ask questions regarding transportation insecurity. Although I am not thrilled with the Health-Related Social Needs (HRSN) wording of questions related to transportation (as I think they are a bit cumbersome, and do not fit into natural conversation), one can easily still assess for patients’ potential transportation needs. Things I would want to know are if my patient is:
Able to drive independently;
Unable to drive or does not have access to transportation;
Uses an insurance transportation benefit;
Uses family or others for rides;
Primarily uses public transportation; or
Has no transportation resources.
Pending a response, one would want to provide necessary resources to the patient, as well as comments to the care team regarding what’s needed for the patient upon discharge to ensure that they are able to head home or to the post-acute facility timely and safely, without avoidable delays related to transportation insecurity. This may be an opportunity to develop outreach and provide resources to patients regarding community support services that allow them to be more successful in obtaining services related to their healthcare. At this time, consults for the post-acute resource center (PARC) could occur to ensure that the patient has a bus pass – or, one might give the transportation coordinator a heads-up that this patient will require a ride at discharge.
From a coding perspective, the conditions impacting the patient’s hospitalization could be assessed if Z59.82, transportation insecurity, applies.
If this information was at the patient level in the medical record, the entire inpatient and outpatient care team could be aware of the transportation modality and provider the patient uses, with access to phone numbers should issues arise.
From a data perspective, this information, listed in discrete fields, would allow the healthcare organization to assess how often patients are presenting with transportation needs and/or potential insecurity. Once quantified, there may be an opportunity for the hospital to partner with an outside vendor for transportation, or to purchase a shuttle to take patients home.
Does your hospital or healthcare organization struggle with patient transportation issues?
Programming note: Listen to Tiffany Ferguson’s live reporting on the social determinants of health (SDoH) Tuesdays on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.
Why Mixed Messages with the Social Determinants of Health
There appears to be an overlap of messages concerning the social drivers of health in the EMR.
This article appeared on RACmonitor.com on February 20, 2023
There appears to be an overlap of messages concerning the social drivers of health in the EMR.
The Centers for Medicare & Medicaid Services (CMS) continues to prioritize efforts with an emphasis on health equity, with greater data reporting and recommended capture of z-codes. I am seeing a lot of mixed messages, with overlap in the electronic medical record (EMR) regarding social determinants and social drivers of health (SDoH).
Social “determinants” is our documentation to support z-codes, while social “drivers” includes our documentation of quality measures for CMS’s value-based purchasing initiatives. I urge EMR vendors and health systems to develop a collaborative and non-siloed approach to capture this information.
How often do we look at information in the EMR for which details have been provided in a similar fashion and are documented in multiple locations? The goal should always be to identify the best location for where important personal information can be found and route everything back to the source of truth in the record. For instance, take a patient’s address.
As a case manager, I often update and find details of this information as we discuss home location with the patient; instead of putting this detail in my note, I ensure that it goes back to the source of truth in the record, the patient’s demographic section.
When adding questions that meet the needs for quality reporting for the five domains of social drivers of transportation, utilities, personal safety, housing, and food insecurity, let’s look at what is already in the record and what can be adjusted to easily match existing workflow. Then let’s ensure that this information is available for all parties.
For instance, if the details of a patient’s living condition are impacting the care plan, that information should be accessible not only to the care team, but also the coding team, to ensure that they can appropriately capture these details. A collaborative session may be helpful, involving clinical documentation improvement (CDI), coding, nursing informatics, quality, and case management, to review the details in the record regarding the SDoH and where this information can be found.
Coding and quality can provide input on the specifications they may need that would help them clearly understand the impact of a particular social determinant on the hospitalization.
In most case management documentation templates, although not consistently used, are fields listing patient limitations or barriers to discharge. These include check boxes and comments for such factors as language barriers, limited social support, and financial stressors.
This information can help guide the coding team, and if any questions arise, via conversations with utilization review or the attending, it is perfectly okay to secure chat or query the case manager for clarification to ensure that we capture these details.
Are you reviewing case management documentation to capture z-codes related to the SDoH?
Programming note: Listen to Tiffany Ferguson’s live reporting on SDoH today on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.
Uncovering Sepsis as a Root Cause of Coding Mishaps
Some vendors will need education as to what criteria need applying.
This article appeared on RACmonitor.com on February 13, 2023
Some vendors will need education as to what criteria need applying.
A recent conversation developed among a client and a vendor that has a longstanding relationship with said client, with the topic at hand being documentation improvement efforts to increase case mix index (CMI) and diagnosis capture for clinical documentation integrity (CDI).
In the utilization review (UR) world, I feel that it is vital to partner with CDI, because documentation is so important to both of us. Why list the diagnoses in the record if you fail to prove the medical necessity for treatment? CDI and UR should be in concert to ensure accuracy of the medical record to justify reimbursement and medical necessity for the care being provided.
During our discussion with the vendor, I raised some concerns we are seeing related to DRG downgrades, particularly associated with sepsis. This was news to the vendor, as they had only been focusing on Medicare and not contractual practices. I then asked the question of what their recommendations for sepsis were, and the answer was that “we strictly follow SIRS (systemic inflammatory response syndrome) criteria for diagnosis of sepsis.”
At that moment, I must have channeled Dr. Erica Remer, because I then made the connection of why the Program for Evaluating Payment Patterns Electronic Report (PEPPER) showed outlier trends centered on coding, particularly for sepsis, as well as continued DRG issues that were masked under “lack of authorization,” “medical necessity,” and “clinical validation” denials or downgrades.
When I asked if they had reviewed the client’s PEPPER, I was looked at as if I had two heads. At this point I realized that our journey to alignment was going to be a little bit longer than I had realized. But I decided to start with a generic example: a patient arrives in the hospital with all the evidence of an infection, meeting SIRS criteria. Sepsis is the working diagnosis while we evaluate what is going on; however, by day 2, it has been determined that the principal diagnosis was streptococcal pneumonia – yet the providers continued to copy and paste “likely sepsis.”
The chart is coded, billed, and then the denial comes, and the payer says, essentially, “we will pay you for streptococcal pneumonia, but we don’t think sepsis was clinically valid.” The finance people may think you have lost money, but the reality is that the patient belonged in the pneumonia DRG to begin with.
Adjusting the principal diagnosis proactively will avoid having to expend the time and money to assess an erroneous denial on the back end. And pneumonia justified medical necessity just fine.
Programming note: Listen to Tiffany Ferguson’s live reporting every Tuesday on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.
The End of the PHE is Near
The unwinding of Medicaid coverage is something to look for.
This article appeared on ICD10monitor.com on February 6, 2023
During the COVID-19 pandemic, our health system saw significant benefits under the federal public health emergency (PHE) waivers. Whether it was the expansion of telehealth or the removal of the three-day inpatient-stay skilled nursing facility (SNF) requirement, healthcare organizations were able to open care to their patients in ways they have not been able to in the past. Socially, we have learned that the PHE provided significant relief of healthcare expenditures for hospitals, particularly with the expansion of Medicaid.
Research now provides evidence that the ripple effect of the PHE has also improved our country’s unemployment rate and decreased concerns over housing insecurity and eviction rates (Bailey, V. 2023). However, as we have already seen, many states are planning to roll back their Medicaid coverage when the PHE ends.
It is estimated that when the PHE ends, tentatively scheduled for May 11, between 5.3 million and 14.2 million Americans will lose coverage, and all Medicaid patients will be required to go through the redetermination process for eligibility. Starting in April, states are expected to meet the requirements for an unwinding process to phase out the continuous enrollment provisions from the PHE (Tolbert, J., & Ammula, M., January 11, 2023).
This is going to have significant impact on our healthcare system, as patient registration and financial services will need to increase efforts to help patients complete their redeterminations, which all likely will result in a huge burden. At any level in the healthcare setting, we can expect changes in Medicaid coverage when patients may be unaware that they have lost their coverage or have a change in coverage. This also will result in delays for services, accessing care, medications, and post-acute transitions. Financially, healthcare will likely experience a rise in denials, bad debt, and uncompensated care. The Centers for Medicare & Medicaid Services (CMS) does have a z-code for those who have insufficient social insurance or are on welfare support: Z59.7.
So, what can health systems do to prepare?
Revenue cycle teams and patient financial services will need to have a good understanding of what will happen in their state when the PHE ends. CMS on Jan. 5 released requirements for each state to develop an operational plan for how they will be “unwinding” coverage from the PHE to their state Medicaid coverage determinations. I have included below a link put together by Georgetown University of each state’s plan and where they are in the process of preparing for the Medicaid rollback.
Connecting with the local department of health and human services (HHS) offices will be vital to ensure that all access points for patient care provide information regarding the changes that will be coming in your local area. Frontline registration, scheduling, and financial assistance staff will want to be aware, and start helping patients obtain information regarding requirements for eligibility, which typically includes submitting updated income statements, tax returns, and proof of home address, such as copies of utility bills. If your hospital does not provide this, it may be a good time to start having conversations, so your healthcare system is not stuck with a significant number of uninsured patients.
Is your hospital or healthcare system prepared for the Medicaid changes when the PHE ends?
Programming note: Listen to Tiffany Ferguson’s live reporting every Tuesday on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer, 10 a.m. EST.
References & Resources
Bailey, V. (January 18, 2023) Medicaid Expansion Helped Reduce Eviction Rates, Housing Insecurity. Public Payer News, Health Payer Intelligence. Retrieved from Medicaid Expansion Helped Reduce Eviction Rates, Housing Insecurity (healthpayerintelligence.com)
Tolbert, J. & Ammula, M., (January 11, 2023) 10 Things to Know about the Unwinding of the Medicaid Continuous Enrollment Provision. Retrieved from https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/
50- State Unwinding Tracker: https://ccf.georgetown.edu/2022/09/06/state-unwinding-tracker/
CMSA Revises Standards of Practice Again
The Case Management Society of America (CMSA) issued revised Standards of Practice for Case Management in 2022.
This article was published on January 12, 2023
The Case Management Society of America (CMSA) issued revised Standards of Practice for Case Management in 2022. The Standards were first published in 1995 and revised in 2002, 2010, and 2016. The general purpose of the Standards is to identify important knowledge and skills for case managers, regardless of practice setting. CMSA decided to revise the Standards again in 2022 in order to emphasize the professional nature of the practice and role of case managers as an integral and necessary component of the health care delivery system.
According to the most recent revised Standards, the definition of case management is as follows:
"Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes."
The Standards go on to acknowledge that explaining case management to clients and the public can sometimes be challenging, so the revised Standards include a definition that can be used for clients and the public as follows:
"Case managers are healthcare professionals who serve as patient advocates to support, guide and coordinate care for patients, families, and caregivers as they navigate their health and wellness journeys."
Revised Standards reaffirm that professional case management practice spans all health care settings across the continuum of health and human services. Occupational therapists, pharmacists, physical therapists, and speech therapists were added to registered nurses, physicians, and social workers as professional disciplines of designated case managers.
The revised Standards also include substantial revisions to the section on Professional Case Management Roles and Responsibilities with a new emphasis on advocacy as a central role and responsibility of case managers as follows:
"The role of a Professional Case Manager concerning the patient is that of advocacy. Advocacy is used to coordinate the influential factors that affect the patient or a group of patients' ability to achieve their optimum state of health. The contributing factors to well-being include Financial, Ethics and Legal, Social Support, and Providers of care."
According to the revised Standards, in order to effectively advocate for patients Professional Case Managers are responsible for being patient-centered and are held accountable to maintain the education and skills needed to deliver quality care. Professional Case managers should demonstrate knowledge of health insurance and funding sources, health care services, human behavior dynamics, health care delivery and financing systems, community resources, ethical and evidence-based practice, applicable laws and regulations, clinical standards and outcomes, and health information technology and digital media for effective, competent performance.
Future articles will cover other changes in the Standards.
Hats off to CMSA for developing and revising these important standards for the discipline of case management!
Making Meaning out of Avoidable Days: Part II
Is it the SNF or is it the payer?
This article appeared on RACmonitor.com on December 14, 2022
In early December I asked our listeners if they knew their top avoidable day reason and if they were willing to chime in with some answers during our live chat segment. Today, I am happy to follow up on many of the responses that I received and thank you so much for those contributions.
The responses aligned with three main categories. Delays related to transitions to the next facility, whether that be a skilled or psychiatric placement. Delays related to family decision-making and social factors. And delays related to internal processes such as not having MRI services on weekends or limitations with consulting specialists.
Although I cannot review all the specifics, I think it is important to note that attribution matters and the only way to solve these problems is to ensure you are capturing enough detail to do something with the information. Enough days calculated for delays in weekend MRI services is likely justification to convince the leadership to hire another radiology technician.
When it comes to post-acute authorizations, I would suggest a deeper look. Is the delay related to the insurance company being slow in their process as reported by the skilled nursing facility (SNF)? Or has the SNF just told you that is the reason when it is an internal issue on their part. The SNF may only look at admission packets once a day or are sending out authorization requests to another department that is likely centralized and in another time zone. Or maybe they are telling you it is because of the payer, but when insurance is called, you confirm that nothing has been received. What is later discovered is the SNF has accepted the referral under ‘payer authorization’ but really does not have a bed available and they just did not want to lose the referral to another facility.
Dig deep and get to the root of the problem. Maybe the case manager is not proactively planning for SNF with clear evidence that the patient meets medical necessity for placement. Has patient’s medical necessity been confirmed in the documentation that was sent over to the payer and SNF for placement requests?
Once the source is evaluated, move into action. If one can discern the cause is the payer, request adjustments in the contract to improve these delays or request additional per diem payments while patients sit in the hospital. If it is the SNF, call this to their attention and discuss with their leadership how you can establish a more streamlined referral process to guarantee a smooth patient transition. If it is because of the case management team, it may be time to complete more training or look at department process improvement efforts.
In all of this I say to our listeners you are not alone, nor do you need to accept that this is your permanent reality. Change can occur!
With that I would like to ask our listeners, are there efforts at your hospital to decrease your avoidable days?
Yes
No
Unsure
Does not apply
The responses from Monitor Monday listeners may surprise you; they can be viewed here.
Programming Note: Listen to Tiffany Ferguson’s live reporting on the SDoH every Monday on Monitor Mondays at 10 a.m. EST.
HINN 12 and What is Next After A Medicare Patient Has Appealed Their Discharge
One cannot place liability on the patient without a safe discharge plan in place.
This article appeared on RACmonitor.com on January 18, 2023
One cannot place liability on the patient without a safe discharge plan in place.
Case management takes on many roles within the hospital setting, but one scenario that typically makes us stop and pause (and maybe add a sigh) is the process required when a patient appeals their discharge. The questions that follow may begin with:
What are our next steps?
Is the patient required to begin payment for the stay?
Can we discharge the patient during the appeal process?
How will the hospital be notified of the appeal determination?
Let’s discuss these questions and solutions to prevent or simplify this seemingly painful process. To begin with, the Hospital Issued Notice of Discharge (HINN-12) process is utilized as the tool and resource for Medicare patients who may be appealing their discharge.
Medicare has given us the HINN tool to be used for reimbursement of a continued hospitalization, after the patient refuses a safe discharge in place. If the patient loses their appeal with the Quality Improvement Organization (QIO), the patient will become financially responsible for the continued stay. This process applies to any patient who qualifies for the Important Message from Medicare (IMM), including Medicare Advantage (MA) plans, Medicare as a secondary payer, or dual-eligible (Medicare/Medicaid) recipients.
Commercial payers may not have an equivalent tool or a concurrent review after a discharge appeal that leads to the patient being financially responsible. Often, these patients remain in the hospital past their discharge date, leaving the hospital without the ability to enforce a discharge or financial responsibility for the continued stay. The HINN-12 process should be seen for what it is: a great tool to keep the discharge process moving while continuing to work with the patient and family to agree to a discharge plan.
STEP 1: THE MEDICARE PATIENT HAS APPEALED THEIR DISCHARGE OR THERE IS AN EXPECTATION TO APPEAL.
The day has come! Case management has worked hard and has an accepting skilled nursing facility (SNF) or post-acute placement plan in place for the discharge today. The hospitalist has either written a discharge or the intent to discharge (the initiation of the appeal process no longer requires a written discharge order). The first question that I always ask the case management team is, “why is the patient appealing?” It is likely that the patient and/or family has an unmet need or fear that is driving the appeal. My recommendation is to get to the bedside ASAP and bring your listening skills before they call 1-800-MEDICARE. Patients and/or their families are likely appealing the discharge related to a fear they may have based off an unmet need, whether it’s realistic or unrealistic. They may have had a spouse die at a SNF or have heard that people that go to a SNF, but never go home. They may be afraid to let home health into their home or they may feel safer in the hospital due to their lack of home support.
Regardless of the reason or the validity of the fear, the concern is real to them. Listening and working to resolve concerns can prevent the appeal from occurring. A different SNF closer to family may make them more comfortable. Maybe accommodation can be made for a family member to stay with the patient in the facility to ease the transition. I would estimate that case management visits to ensure a collaborative discussion and patient transition will help avoid a discharge appeal, and it is well worth case management’s time to enhance the patient’s satisfaction level with the discharge.
STEP 2: THE PATIENT HAS APPEALED. WHAT DO WE DO NOW?
Ok, the patient has appealed, so on to the next steps. Maybe you have not had a Medicare appeal recently, or maybe you have never handled one. What will happen next? Well, your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) is going to reach you by the method your hospital provided to them.
The two QIO organizations are Kepro and Livanta, and they are assigned by state. The QIO has a designated contact at your facility where they will send the appeal letter and required document request. The requested documents need to be returned to the QIO within 24 hours. Due to this timeline, the method by which the QIO letters come in should be monitored by someone in case management at all hours that the department is operating. If the requested documents are not returned by the hospital to the QIO in the requested timeframe, the QIO will agree with the patient on the appeal. This will prevent the hospital from proceeding with the HINN process or attributing financial liability to the patient, thus limiting the hospital’s ability to move forward with discharge.
The documentation request from the QIO will include the IMM that was signed by the patient and a copy of the signed Detailed Notice of Discharge (DND). The DND letter can be found on the Centers for Medicare & Medicaid Services (CMS) website and must be given to the patient when they appeal to the QIO. On the DND notice, you will indicate why the patient’s hospital stay is no longer required and why Medicare payment for their stay is ending due to lack of medical necessity.
To proceed with the discharge appeal process, case management must ensure that there is a safe discharge plan in place throughout the appeal process. If at any time the safe discharge is no longer available, the patient will remain in the hospital. An example would be that the patient is expected to discharge to a SNF and the bed is no longer available, and there is no other safe discharge backup option in place. You cannot place liability on the patient without a safe discharge plan in place. One of the most common questions asked is this: is the patient required to remain hospitalized during the appeal? The answer is yes. The appeal occurs because the patient feels they are not ready for discharge, therefore they remain in the hospital until the appeal is complete.
STEP 3: YOUR QIO AGREES THAT THE PATIENT IS APPROPRIATE FOR DISCHARGE. WHAT HAPPENS NOW?
The QIO has 24-48 hours to make a decision on the appropriateness of the discharge. My experience has been that in most cases, if you have submitted the documents they have requested and confirmed a safe discharge plan, the QIO will side with the hospital. Once you receive the QIO decision, you can inform the patient that their responsibility for the hospital bill will begin on the following day at noon, if they have not been discharged from the hospital by that time. The letter provided to the patient should outline the reason they no longer meet medical need for inpatient hospitalization, the date upon which they will be financially liable, and the estimated total or average daily cost, beginning from the date of noncoverage. This letter must be signed and dated by the beneficiary. If they refuse to sign it, you can indicate that on the form. This can be a difficult conversation to have with a patient and/or family. My approach has been to take the manager/director of patient billing along to meet with the patient. They should bring information on the expected daily costs to begin the next day at noon. Be sure to have conversations with your leadership once this HINN-12 process begins. There will likely be lots of discussion prior to asking the patient to pay for their stay regarding how your organization will decide to handle that sensitive topic.
STEP 4: WHAT? A SECOND- AND THIRD-LEVEL APPEAL?
Yep! A patient has the right to a second- and third-level appeal if they continue to refuse the discharge plan. But after the patient loses the first-level appeal, the financial liability falls onto the patient if they choose to remain in the hospital. The second-level appeal process for Medicare Fee-for-Service (FFS) will take 1-3 days for a response, for a hospitalized patient. The medical record review will be the same information as submitted on the first version, but will be reviewed by a different physician than during the first appeal review. On the second review, the family is permitted to submit pertinent documentation. A second-level review for a MA plan may vary, dependent on the payers. Reach out to the MA plan on all appeals to verify their appeal process and documentation requirements.
The third-level review will occur as an Administrative Law Judge (ALJ) hearing. The office of Medicare Hearings and Appeals (OMHA) is responsible for administering ALJ hearings. MAXIMUS is the Federal Services for the Part C Independent Review Entity (IRE). Any party in the appeal process may appeal to the Medicare Appeals Council if they are dissatisfied with the outcome of the ALJ decision. To dig into more details on these higher levels of appeals, go to https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/BFCC-QIO-Review and dive into the QIO manuals and everything related to the appeals process.
Hospitals should have an outlined policy for how they address patient appeals, as case managers will want to ensure that they are trained regularly regarding this process. Patients appealing their discharge should not be a hospital common occurrence; however, we are seeing it occur more frequently in our collaborative health systems across the country.
Reviewing these cases will be helpful to make sure that the necessary steps are taken to ensure compliance, and to see if this could be avoided in the future.
Should I Hire Someone Without Case Management Experience?
Healthcare has gone through so many changes in the past three years.
This article appeared in the Case Management Society of America Blog in November 2022. You can find it here: https://cmsa.org/should-i-hire-someone-without-case-management-experience/
Now that we are settling into what feels like our new normal, staffing is more of a challenge than ever before. Recently, I had a discussion with hospital leaders regarding the recommended amount of experience when hiring a new case manager. Once the conversation began, there were varying opinions with a focus on ensuring the development of a case manager who works as an advocate for the patients with an understanding of the business of healthcare. Ideally, leaders look for an applicant with 3-5 years of case management experience. We also hope for several applicants to interview and choose from. Unfortunately, in the current market, we are lucky to have one applicant for a position in the first few months that it is posted. While experience is always preferred, an applicant with the right qualities can succeed. The focus needs to be on core curriculum and training from a tenured staff who can educate, orient and offer ongoing mentorship.
So, the question I pose is: can you hire a new graduate or someone with no previous experience as a case manager? My answer is yes, and before you gasp out loud, there are considerations and steps that can assist in hiring the right person with the right qualities to succeed in the demanding role. Below, we will discuss how you can determine those qualities during your search, focus on a successful orientation and develop a program that supports personal growth and advancement as a case manager. For the record, I agree that an experienced case manager is always best. The BUT is that, like the housing market, the inventory is low and the demand is high so thinking outside of the box is necessary to meet the needs of our patients and our communities.
Interviewing For Your Next Case Manager
While completing your interviews, you must think of the qualities required to be an effective case manager. Skills can be taught, but attitude and work ethic must be considered equally as attributes to success. Core qualities are required for an individual to advocate for a patient, confidence to interact with physicians and be assertive enough to facilitate a group in conversations with multidisciplinary teams. Case managers problem-solve under stressful situations and need to work autonomously. Hiring for these qualities and the ability to handle difficult situations will benefit of the patient, team members and the organization.
While interviewing, use questions that identify excellent communication skills led by critical thinking and self-confidence. Is this person going to be able to multitask throughout the day? Can they identify and prioritize patients who are ready for discharge today and ensure the plan is in place? The ability to quickly adapt to changes in the plan and redirect the focus required for the patients’ discharge takes patience and skill to prevent discharge delays for complex patients.
Questions that can be asked to look for this candidate who has the attributes that you are looking for may be:
Tell me about a time when you realized you needed to make an improvement in your communication skills. How did you manage it?
Tell me a time that you worked with a person whose personality was the opposite of yours. How did you manage your relationship?
How do you organize your work to ensure that you are the most effective and productive?
What have you done that was innovative?
Orientation Success and Outcomes
We were not born case managers and we all started somewhere as a new grad. The variation lies in how effectively we were trained when we began. My first job was on a long-term care unit. I was 22 and I looked about 17! I was told that I would receive 6-8 weeks of orientation. The first night, I received orientation and worked alongside a nurse. The second night I was “on my own” due to staffing and the need for coverage of a patient assignment. And the third night I was the charge nurse because she had called off and everyone else working had floated from another unit. Thank goodness, I returned to an orientation schedule the following week. But now, as a leader, I see how the system failed me as a new grad and the lack of support for me to receive proper training. Not to mention patient safety!
Orientation of a new grad, whether as a nurse or social worker, will require additional time to orient than those with prior experience. A case manager boot camp curriculum and education discussing best practices for transitions of care, utilization review, regulatory requirements and need to know items for your community will benefit those coming into the profession. For new social workers, an additional boot camp piece related to key medical wording, diagnoses and disease processes would be beneficial due to their lack of medical education during their social work program.
Retaining Staff and Investing in Staff Advancement
The knowledge and skills that an organization arms their staff with will pay off through the care provided to the patient and the understanding of the continuum of care for best patient outcomes. Those of you reading this article are involved in the CMSA, which means you are putting in the effort to continue to learn by participating in this community. But are your team members involved? Are those who report to you involved? And if not, why not and how to we get them involved? Think of what can be done to get more of your staff involved in case management associations and certification once eligible. Certifications offer case managers the ability to promote their advanced knowledge to their patients, families, and colleagues. It reflects a higher level of commitment and encouragement of these advances which assists solidify the future of this professional’s path within the case management profession.
The changes in hiring challenges don’t appear to have an end in sight and there won’t be an easy fix to finding experienced team members. Maybe you will not decide to hire new grads but do look at your requirements in your job descriptions. Could you lower the required years of experience to attract more talent? What can you do to adjust your orientation program to have a more comprehensive approach to meet the needs of a new hire with little to no experience? We need to broaden our scope to meet the demands of this new hiring market. Good luck to you all!
Bio: Marie Stinebuck MBA, MSN, ACM is the Chief Operating Officer of Phoenix Medical Management, Inc., the leading case management firm. She has practiced as a nurse for the past 25 years with 17 years in the field of case management and has served in several roles in senior leadership roles in Case Management. Marie has also authored numerous articles, is a weekly contributor on Finally Friday and is a Board Member for the Arizona ACMA.
Why Is That Patient Still Here?
As case managers, we have all heard the question, “Why is that patient still here?”
This article appeared on the CMSA.org blog in August 2022. View the original article at https://cmsa.org/why-is-that-patient-still-here/#comment-2486
Rounding and Complex Patients
As case managers, we have all heard the question, “Why is that patient still here?” The question may have come from the attending physician or maybe from senior leadership, but the question is always directed to the case manager! While these complex cases can feel overwhelming, there are strategies to be used that increase the efficiency of discharging these time-consuming patients. The use of daily interdisciplinary rounds and establishing processes for further review of complex cases develops pathways for difficult cases towards a transition of care plan while expediting difficult discharge barriers.
Daily Rounds and Progression of Care
Daily interdisciplinary rounds should occur at the same time and location every day with attendance by the case manager, floor nurse or supervisor who has rounded on all patients on the unit, utilization review, physical therapy and physician advisor or attending, dependent on your model and availability. If you move the meeting time or location, you may lose attendees. Keep it consistent Monday through Friday so that they become part of the team's daily routine. Weekend rounds are not usually possible as we drop to a skeleton crew and put out fires all day! Additional attendees can include pharmacy, palliative and dietary care on specialty units such as the ICU. The focus of daily rounds is a progression of care for patients who are expected to discharge today or tomorrow. A few questions that need to be answered: What are the barriers? From a medical perspective, what needs to occur for the patients to discharge? What does the CM need to do today for the patients to be ready on their discharge date? These rounds need to move quickly through, likely 1-2 minutes per patient and typically occur on or near the nursing unit.
Complex Cases
Complex cases that are length of stay outliers occur related to medical and social situations and should be discussed during a weekly meeting. Locations of this meeting can be rounds to the units, case manager offices or in a meeting room. Discussions include patients who may be without a payer, are from another country, have guardianship or ethical issues, social or financial barriers that affect discharge and other outlier complexities that are individual to each patient. Regardless of which of these apply, these patients are typically very time-consuming and can become outlier patients who affect bed capacity and burnout of the hospital staff who care for them. They may also use an inappropriate amount of hospital resources during a time when healthcare is already incredibly strained and exhausted. With the current shortage of bedside nurses, the importance of this population of patients can affect daily operations in hospitals with a shortage of beds and staffing.
Weekly complex case review rounds can occur as physical rounding to the units or case manager offices or as a meeting in a designated space. Regardless of how your facility decides to process, this will meet the Medicare Conditions of Participation 482.30. The condition requires hospitals to conduct a review of duration of stays and professional services and for the meeting minutes related to these complex meetings. These meeting minutes need to be elevated to the Utilization Management Committee (UMC) for review. As stated above, the complex rounds meeting should occur once a week and include the case manager, social worker, case manager director and a Physician Advisor or Chief Medical Officer (CMO) in attendance. Additional stakeholders can include finance, palliative care, admissions and anyone who your organization feels adds value to the meeting. This is your meeting; make it work for your organization!
The length of stay of the patients discussed should also be determined by your team. Don’t decide on a 7-day length of stay review for this meeting and then discuss patients who are appropriate in the ICU at day 7. You may decide on a LOS of 7 days for med/ surg and 10 days for ICU. Find a starting place and adjust as needed to address those patients who are truly outliers. Case managers should also be encouraged to bring patients, even if it is the day they are admitted, that are obviously going to be a discharge challenge. Seasoned case managers will recognize these patients during the initial assessment. Talk about them early and start working on a plan as a team if you already know that they are likely to become an outlier.
Daily rounds create a forum to discuss those patients who should discharge today or tomorrow and ensure we have their needs addressed. Weekly complex discharge rounds give a place for the more complex patients to be discussed in more detail related to their individual needs. The use and combination of these two meetings will improve communication between the caregivers and stakeholders invested in the cost of care, progression of care and improved outcomes of the patients. Discharging these patients is a team effort and should involve senior leadership when required. Next time, they will not ask you why the patient is still admitted. Instead, they will be involved in the process and celebrate with you when that difficult patient has left! Complex patients may continue to increase and we, as case managers, will continue to work diligently to ensure they move safely and efficiently through the progression of care.
BIO: Marie Stinebuck MBA, MSN, ACM
Marie is the Chief Operating Officer of Phoenix Medical Management, Inc., the leading case management firm. Marie has practiced as a nurse for the past 25 years with 17 years in the field of case management. Marie has served in several roles in Senior Leadership roles in Case Management. Marie has authored numerous articles, is a weekly contributor on Finally Friday, and is a Board Member for the Arizona ACMA.
For more on how to move patients safely and efficiently through the progression of care, explore the online course "Improving Transitions of Care: What’s Working and What Have We Learned?" at https://www.pathlms.com/cmsa/courses/36380 (FREE to members!)
Making Meaning Out of Avoidable Days
Avoidable days can impact patient care and social determinants of health (SDoH).
This article appeared on RACmonitor.com on December 7, 2022
Avoidable days can impact patient care and social determinants of health (SDoH).
I always love working in the hospital with my fellow case managers, because it reminds me of the relevant issues and topics that colleagues are facing when they show up for work each day.
Today, let’s talk about avoidable days and discharge delays that occur with our patients, and how they can meaningfully impact patient care and social determinants of health (SDoH).
Avoidable days are tracked or logged delays in patients’ progression of care and/or discharge that have led to resource consumption without medical necessity. These days are often categorized by reason and attribution.
For instance, say a patient with a discharge order stayed overnight because they did not have a ride home. The reason is transportation, but the attribution may be nursing, because they did not phone a friend and figure it out. Or consider the patient who waited two days for a consultant to provide services and advise on the care the patient needed. The reason may be cardiology delay, and the attribution is Dr. X of blank cardiology group. Or consider the social admission wherein it is determined that the entire stay should be tracked as “avoidable.”
Whatever the reason, the goal for tracking these days is not to project them as a meaningless trend line, with a goal to artificially decrease them; this would result in people no longer reporting reasons!
The only reason this information is tracked is so the hospital and/or health system, likely through the case management department, can do something with it and impact change.
If you do not know your hospital’s internal costs, we can estimate, according to Kaiser Family Foundation 2020 national hospital data, that it is about $2,800, per patient day (see reference below). Then you can quantify the numbers to dollars and decide which services should be covered to support the patients’ care delivery and transition of care.
Going back to my original example, if you have one patient per week who stays overnight because “they didn’t have a ride home,” that is about $145,000 in annual waste, or 3 EVS workers. Turn the information into action by creating a story, as a hospital leader, for example by reaching out to a key foundation, collaborating with your community or post-acute providers, or painting a clear picture for executive leadership and the CFO on what reduction means. I also have justification for why the hospital should just easily cover the ride for the patient home – better yet, with a to-go meal and their prescriptions filled!
I could ask this question in a lot of ways, but I am going with this: do you know the top avoidable day reason at your hospital or health system?
Yes
No
We do not track avoidable days
Does not apply
The responses from Monitor Monday listeners may surprise you; they can be viewed here.
Programming Note: Listen to Tiffany Ferguson’s live reporting on the SDoH every Monday on Monitor Mondays at 10 a.m. EST.
Report: U.S. Charity Care Provided by Hospitals Leaving Much to be Desired
Healthcare provided to the most vulnerable populations often constitutes a tiny sliver of overall hospital budgets.
This article appeared on RACmonitor.com on November 16, 2022
Healthcare provided to the most vulnerable populations often constitutes a tiny sliver of overall hospital budgets.
Kaiser Family Foundation (Levinson, Hulver, & Neuman, 2022) recently released a report on national charity care levels for hospitals and health systems illustrating some dire financial news.
The report acknowledged that approximately 58 percent of U.S. households are currently earning below an annual income of $40,000, and estimated personal medical debt across the U.S. has reached approximately $195 billion.
However, charity care only represented 1.4 percent or less of total operating expenses at half of all hospitals in 2020, with significant variations across hospital designations. Additionally, it was found that 8 percent of all hospitals had 0.1 percent of operating expenses related to charity care.
It was also noted that there was no meaningful difference in charity care contributions between government, for-profit, and nonprofit hospitals. This was surprising, since as you know, nonprofit hospitals receive significant tax exemptions. The article did mention that despite nonprofit status, which makes up about 58 percent of all community hospitals in the U.S., many states have requirements that set expectations for all hospitals regardless of tax exemption to provide some level of charity care.
Before I throw some hospitals completely under the bus, I do want to acknowledge some factors that may contribute to the low numbers, which include potential discrepancies among hospitals in attributing charity care versus bad debt/write-offs.
However, many health systems were cited as not updating their charity care policies, and according to a 2021 study from Sage Publications on charity care, they found that in 2018, a total of 32 percent of hospitals continued to have stricter policies that expected patients to be at or below 200 percent of the federal poverty level. Understanding that many of these patients are likely already on Medicaid means very few such patients are actually receiving the benefits of full charity care. About 62 percent of hospitals in the study were found to offer discounted care for patients at or below 400 percent of the federal poverty level; however, it was reported that the definitions of “discounted care” were inconsistent across health systems (Bai, et.al, 2021).
In my continued digging, I was able to find a Journal of the American Medical Association (JAMA) study by Goodman, Flanagan, and Probst, who completed a cohort study of the top 170 nonprofit hospitals in the U.S. They found that 47 of the hospitals actually expanded charity coverage during the pandemic, while 12 hospitals further restricted their charity care, with the largest restriction being residency requirements for home locations within the community hospital region – and U.S. citizenship requirements. Some unusual exclusions were also found, such as denying charity care for birth control, or specialized outpatient services.
Do you think your hospital and/or health system is giving enough in charity care for your community? The responses from Monitor Mondays listeners may surprise you; they can be viewed here.
Programming Note: Listen to Tiffany Ferguson’s live reporting on the SDoH every Monday on Monitor Mondays at 10 a.m. EST.
Final Rule on Rural Healthcare Services
Release of the REH designations for 2023, indicates that CMS will only be covering outpatient, emergency, and observation care services.
This article appeared on RACmonitor.com on November 9, 2022
Release of the REH designations for 2023, indicates that CMS will only be covering outpatient, emergency, and observation care services.
Last Tuesday, the U.S. Department of Health and Human Services (HHS) released new updates to address health equity by increasing rural care access.
A press release made official the earlier proposed place of service titled Rural Emergency Hospitals (REHs). This designation will allow Critical Access Hospitals (CAHs) and small rural hospitals the opportunity to convert to REHs. When I reported on this back in August, there was concern that the REH designation would not cover inpatient services.
This has been confirmed with the release of REH designations for 2023, as they would only be covering outpatient, emergency, and observation care services. Similar to other place-of-service designations, the REH requirements establish a full range of health and safety standards, including requirements for services offered, staffing, and physical environment and emergency preparedness.
More specifically, REHs require:
A clinician on-call at all times and available on site within 30 or 60 minutes, depending on if the facility is located in a frontier area;
24/7 staffing to address emergency medical care with appropriate licensed professionals;
Maintaining and submitting ongoing data requirements for Quality Assurance and Performance Improvement Program (QAPI);
Annual per-patient average length of stay not to exceed 24 hours, and the time of calculation begins with registration check-in or triage and ends with the discharge time from the REH; and
An infection prevention and control and antibiotic stewardship program.
Okay, well, this is what it is, and thus rural hospitals or CAHs will have to decide if it is worth switching to the REH designation.
Additionally, Medicare is expanding the promotion of hospital outpatient departments to reimburse for remote behavioral health services provided to people at home. The Centers for Medicare & Medicaid Services (CMS) first implemented this policy through emergency rulemaking in response to the COVID-19 public health emergency (PHE). CMS has now officially made this ruling permanent to ensure continued access to behavioral health services via telemedicine in hospital outpatient departments. This rule requires that beneficiaries receive an in-person service within six months prior to the first-time hospital clinical staff provision of behavioral health services remotely, and there must be an in-person service within 12 months of the behavioral health service being furnished remotely.
CMS is clarifying if audio-only communication can be used, if video and audio capabilities are not available for remote services. They have made the intention clear that they do not want to discourage availability of behavioral health access because of technology limitations; however, I would just suggest that in all cases, ensure there is proper documentation to cover how the remote service was provided and why the patient could not do video, should this be an issue.
Today I ask a generic question: is your hospital or health system ready for all the 2023 CMS changes? The responses may surprise you; they can be viewed here.
Programming Note: Listen to Tiffany Ferguson’s live reporting on the SDoH every Monday on Monitor Mondays at 10 a.m. EST.
Why Has the Hospital Turned into Long-Term Care?
Often, the ability to move such a patient from the hospital into an appropriate setting is dependent on the social services in the local jurisdiction.
This article first appeared on RACmonitor.com on October 26, 2022
Theoretically, we know that patients needing custodial care are not supposed to be in the hospital without medical necessity, but in many cases, they show up in the emergency room and are admitted into the hospital because there is nowhere else for them to go.
The emergency-room physician believes that they can’t safely discharge the patient from the ED; however, they have no idea that once that patient, often a senior, goes upstairs to the hospital floor, the problem continues. Have we solved the problem, or have we just moved the problem from the ED to the hospital unit?
What happens next is often that the patient becomes a permanent resident of the hospital while the case management team attempts to mission-impossible a plan that will try to figure out supports, financials, long-term benefits, and all the logistics of getting this type of patient into permanent supportive housing. For every hospital our team visits, and in discussions with various healthcare leaders on this topic, the story is consistent, and unfortunately, not unique.
Often, the ability to move such a patient back into an appropriate setting is dependent on the social services in the local jurisdiction and the state governmental policies that exist for long-term benefits and permanent supportive housing. There are so many social complexities with these cases, many of which have nothing to do with the hospital setting. These patients can be in the hospital for months to years…yes, years…I have seen it!
According to the American Health Care Association and the National Association of Assisted Living, more than 325 nursing homes have closed since the pandemic, with another 400 expected to close by the end of 2022, based on current financial trends. And although I see plenty of assisted living homes popping up, many places that are closing are smaller facilities, meaning fewer than 100 beds, with at least 60 percent of their occupancy being Medicaid-dependent.
Based on the previous closures, most of these facilities had 4–5-star ratings on Medicare.gov. Additionally, it is reported that if the Public Health Emergency (PHE) ends, which would mean reductions to Medicare and Medicaid, an additional 32-38 percent of nursing homes would be at risk of closure. The total estimate is 417,000 seniors who would be at risk of losing their housing.
Alternative options are also limited, as low staffing levels continue to impact home care services in the home health and private duty sectors. The hospital is clearly not the best place to be, but where else are these patients supposed to go? I will continue to research this topic, and would love to hear from health systems and organizations that have come up with innovative approaches to solve this problem, to share on future broadcasts. Please feel free to email me at tferguson@phoenixmed.net.
Today I ask, are your health systems having difficulty with social admissions because of a lack of permanent supportive housing? The responses from the Monitor Mondays Listeners Survey may surprise you; they can be viewed here.
Programming Note: Listen to Tiffany Ferguson’s live reporting on the SDoH every Monday on Monitor Mondays at 10 a.m. EST.