A few weeks ago, during the weekly Monitor Monday broadcast, healthcare attorney David Glaser presented a great segment that simplified the two-midnight rule into two essential parts: first, that a patient must require hospital care, and second, that the need for that care must be expected to span two midnights.

Yet despite the clarity of these conditions, why does conflict persist between payers and hospitals on how this rule is applied?

One main issue is that some payers still need to fully recognize the rule despite clear regulations. However, a more significant challenge stems from differences in defining and understanding what constitutes hospital care.

This leads to an important question: What exactly is hospital care? Is it simply any skilled service provided within the hospital walls? Alternatively, is it a restrictive definition used by many Medicare Advantage companies, where a patient must meet strict third-party criteria to qualify?

What does it mean for a patient to require hospital care? For insight, we look at Rule 1599F—the two-midnight rule—which clarifies that “The crux of the medical decision is the choice to keep the beneficiary at the hospital in order to receive services or reduce risk or discharge the beneficiary because they may be safely treated through intermittent outpatient visits or some other care.“

If the required care could be delivered safely outside the hospital or in a less intensive setting, it should not count toward the two-midnight benchmark. Notably, the decision should be evidence-based rather than it be convenient for the patient or physician, and external, third-party criteria should not dictate it.

In my most recent segment during the Monitor Monday broadcast, I discussed how an order for observation services indicates that the physician cannot confidently predict a patient will need hospital care for over two midnights. Per the guidance above, on day two of the hospital stay, the patient must be discharged, or documentation to substantiate the need for ongoing hospital care must be present.

Based on the above guidance from the two-midnight rule, this documentation should expressly state or make obvious why the same care cannot safely be provided elsewhere or through periodic outpatient visits. Unfortunately, in our busy healthcare environment, physicians often rely on templated language that needs more specifics on patient acuity or the unique need for ongoing hospital care.

For example, I was able to overturn a denial on peer-to-peer review for a patient with chronic obstructive pulmonary disease (COPD) on room air when the physician documented persistent shortness of breath, tachypnea, and the need for IV steroids. However, despite similar presentations, a patient whose chart stated they had “improved since admission” and whose exam appeared as a generic template was denied because the documentation did not support the need for hospital care.

Both required hospital care, but only one was paid as an inpatient.

At my previous organization, we piloted an initiative to address documentation gaps. Adding a dedicated section to the physician’s note template prompted hospitalists to include one concise statement, based on their medical judgment, explaining why the patient required hospital care and could not be discharged. The documentation was to be based solely on the medical rationale and proposed or required treatment and not consider social or other discharge barriers outside the physician’s control.

We wanted them to tell us when the patient was medically cleared and, if not medically cleared, why not. As you can imagine, implementing this required substantial engagement and education and did not happen overnight. Physicians struggled to distill this information into a statement other non-physicians can understand. They are taught to list diagnoses and the appropriate treatment for that diagnosis.

No text or handbook provided in residency teaches young physicians when patients should be discharged. These practice patterns are institutional and passed down from attendings to residents.

However, in implementing this process, I found that many young hospitalists assumed that someone had determined they needed to be in the hospital because the patient was there. Many didn’t even realize people were looking to them to help with these decisions. I won’t lie; getting this to change takes some heavy lifting, but it ultimately streamlined the status process, reduced denials, and increased overturn rates during peer-to-peer reviews. It also improved communication and participation in multidisciplinary rounds, which helped the care management team organize discharge plans for skilled nursing facilities, home health, and other services.

Instead of the discharge process being worked “in series,” where the care management team would have to wait until the physician cleared the patient to start working on placement, our goal was to have parallel processes that lined up at the same time, thus reducing unnecessary delays waiting for acceptance, authorization, supplies, etc. This proactive coordination significantly decreased avoidable hospital days and length of stay, benefiting both patients and the hospital.

In sum, the two-midnight rule is evident in its intent, but clarity in documentation supporting the ongoing need for hospital care is the third essential step in reducing denials and preventing audit takebacks.  Collaboration between the Physician Advisor and hospitalist medical director is required to provide physician education and promote engagement and buy-in.

However, the reality is we overcomplicate the two-midnight rule. The rule is clear. It’s often the documentation and rationale that is missing. If you can get that part in order, it is as easy as one, two, three.

In today’s complex healthcare landscape, regulatory compliance, revenue optimization, and operational efficiency are critical for success. Certus Radar is designed to tackle these challenges head-on. Our innovative proprietary platform, built with direct input from seasoned Physician Advisors and revenue cycle experts, ensures that hospitals stay compliant while maximizing their revenue and operational potential.

Here’s how Certus Radar achieves these goals:

Certus Radar was built by Physician Advisors and revenue cycle experts who understand the intricacies of clinical and regulatory standards. Our expert team has decades of experience interpreting regulations and supporting compliant revenue cycle practices.

Hospitals never sleep, and neither does Certus Radar. The platform is designed to function continuously, even during off-hours, holidays, and staff downtime. This ensures that utilization management processes remain optimized all the time, preventing costly delays, maintaining operational efficiency and fully capturing earned revenue.

Revenue capture can be a complex and challenging process, but Certus Radar simplifies it by combining expertly designed case automation with the clinical expertise of Brundage Group Physician Advisors. The platform monitors patients admitted to the hospital to optimize patient status verification by accurately determining which accounts need to be escalated to a Physician Advisor as well as determining the optimal time for the review to occur. Allowing UM staff to focus on the right patients at the right time, preventing revenue opportunities from slipping through the cracks. Accurately determining patient status as early as possible reduces revenue leakage and optimizes the use of hospital resources.

In healthcare, timely and actionable data is essential. Metrics that reflect the accuracy and efficiency of utilization review efforts are often overlooked but play a vital role in the financial health of a hospital. Certus Radar provides real-time analytics through key performance indicator (KPIs) dashboards that impact a hospital’s financial health. From optimizing staff schedules to improving overall operational efficiency, the platform’s real-time insights allow hospital leadership to make data-driven decisions that positively impact financial health and operating margins.

Hospital inpatient utilization management (UM) is crucial in the healthcare industry, ensuring hospital resources are used appropriately and efficiently. UM involves assessing the necessity and efficiency of the care provided to patients impacting healthcare costs for the patient and the hospital. Effective utilization management processes can significantly impact hospital operations and financial health in several ways. Ensuring compliance with payer requirements contributes to better cash flow when payments are made promptly. Reducing claim denials also promotes better cash flow but, more importantly, it reduces administrative and financial burdens associated with the appeals process.

Hospital utilization management strategies involve systematically evaluating and managing hospital resources. Key activities include pre-admission screening, concurrent review during hospital stays, and retrospective review after discharge. These activities help ensure that medically necessary care is delivered in the most appropriate setting.

The goals of utilization management include:

• Ensuring appropriate use of hospital inpatient resources and services.
• Reducing unnecessary hospital admissions and lengths of stay.
• Enhancing hospital compliance with payer requirements and regulatory standards.
• Minimizing financial losses due to claim denials and revenue leakage.

UR is a critical component of hospital UM functions, involving the evaluation of the medical necessity, appropriateness, and efficiency of healthcare services. UR processes include assessing admission criteria, reviewing ongoing patient care, and verifying when a patient has met discharge criteria.

The Medicare Two-Midnight Rule is a critical regulation in UR, stipulating that inpatient admissions are generally appropriate if the physician expects the patient to require hospital care spanning at least two midnights. This rule, codified for Medicare Advantage Programs (Medicare Part C), guides hospitals in determining the appropriate patient status.

Education is essential for both hospital UR staff and admitting providers. Education and training for UR staff are vital to ensure they can effectively evaluate medical necessity. Skilled UR staff can make informed decisions that align with payer requirements, reducing the risk of claim denials and ensuring compliance. Training providers to understand UR protocols helps ensure that patient admissions and services meet medical necessity criteria, reducing the likelihood of claim denials.

Ineffective UR processes can lead to significant revenue leakage for hospitals. UR staff need to review the right patient at the right time, which varies by setting and payer. Failure to complete a timely review can result in claim denials and financial losses. Proper workflows are essential to prevent these issues.

Medical necessity is a critical factor in accurately determining patient status. Hospitals must ensure UR staff have the skills and knowledge to assess medical necessity effectively and appropriately by payer. This includes understanding clinical guidelines and applying appropriate screening criteria.

Hospital UR staff benefit from the support of a Physician Advisor. Physician Advisors provide expert medical judgment beyond standard screening criteria. This collaboration enhances the accuracy of patient status determinations and reduces the risk of claim denials.

At Brundage Group, we offer comprehensive services to support hospital inpatient utilization review activities to minimize and prevent revenue leakage. Brundage Group can support your UR department every step of the way. Our unique approach allows our Physician Advisors to seamlessly integrate into the UR workflow where we provide expert guidance, ensuring accurate patient status determinations that comply with payer requirements. Due to the importance of getting a patient in the right admission status as quickly as possible, we also offer utilization review education to enhance the skills of your admitting physicians. Lastly, if a denial is received from the payer, Brundage Group can represent the hospital during the peer-to-peer process and assist with post-discharge appeals.

Contact Brundage Group today to learn how we can help your hospital capture earned revenue and optimize utilization management processes.

Dive in deeper to understand this integral component further.

Let’s delve deeper into the significance of utilization management in healthcare. UM is vital in maintaining quality, managing risks, and ensuring cost-effective care provision. This is the main focus of this healthcare practice, which strives to improve patient outcomes. Early intervention tactics and preventive care measures are applied to prevent serious complications before they arise. Ultimately, this results in reduced costs for hospitals and health systems over extended periods of time.

Regular check-ups facilitate the timely detection of potential diseases, resulting in prevention rather than cure scenarios, which is always beneficial.

Concurrent review procedures allow effective monitoring of treatments throughout the medical facility’s duration of stay. This emphasizes a focus on the optimum length of stay and initial discharge planning initiatives. Additionally, post-discharge retrospective reviews provide valuable insights that can be used for continuous improvement. These reviews evaluate the appropriateness of services that were provided in the respective settings.

Moreover, ensure that professional guidance from experienced clinicians supervises these processes, as they bring forth critical thinking abilities aiding informed clinical decisions.

Lastly, remember that good UM programs aren’t just financially driven and prioritize improved patient-centric results.

The most effective utilization management strategies focus on four core components: risk minimization, quality assurance, patient education, and in-depth review. In managing risks, the goal centers around reversing disease processes through early intervention and preventive health measures. This not only enhances overall population health but also keeps costs low.

Quality assurance involves regular audits to ensure regulatory compliance and appropriate use of medical necessity guidelines. An emphasis is placed on this for creating actionable data from audit results.

Reviews of patients take place at different stages: prospective reviews occur before treatment begins, concurrent reviews happen during treatment, and retrospective reviews happen after discharge. These reviews help to determine if various parameters, such as length of stay or discharge plan execution, were appropriate.

In the utilization review process, careful checks take place. An initial evaluation occurs when a patient is admitted to a healthcare facility. This assessment revolves around medical necessity and justifiable care levels suitable for the individual’s case. This can help save significant costs in the long run. Furthermore, it involves monitoring any potential delays in care and evaluating how well progressive treatment is advancing for that individual. These evaluations occur while your loved one resides in either acute or post-acute settings within such facilities.

After these treatments are carried out, retrospective reviews are conducted. Coverage audits are then carried out after the respective therapies have been given to ensure maximum transparency. Additionally, don’t forget about precertification; this is part of a complete utilization review, assuring that scheduled services are done accurately from before admission until all necessary actions have been completed.

Thus, woven into its core practices is effective cost containment without compromising on quality health outcomes, making Utilization Management truly key when optimizing healthcare service delivery!

You need to define processes clearly to make your utilization management program deliver optimal results. Show each team member’s role and responsibility in a concise manner. This step ensures high-quality outcomes that can be repeated with ease.

Appoint an experienced Physician Advisor to oversee the process of UM reviews. Their deep understanding of healthcare policies and standards is invaluable in guiding nursing staff on best practices.

A robust quality improvement plan is essential for any successful utilization management initiative. It ensures regulatory compliance and helps ensure effective medical necessity guideline usage. Audit findings can be used to inform strategic action, such as revising training materials or refining workflows based on feedback from the audits.

Consistency across all these components paves the way toward an improved patient care journey. This should remain at the heart of every measure taken within your UM framework.

Choosing a reliable UM Physician Advisor requires careful consideration. You should carefully scrutinize potential partners for their proven track record in the industry.

Remember to ask about compliance standards, too! A first-rate utilization management firm always educates physicians on compliant documentation while reviewing each case.

Moreover, understanding how quickly they respond when peer-to-peer reviews are requested speaks volumes about their competence. In conclusion, choosing a proficient UM service provider isn’t just smart business; it’s central to ensuring accurate compensation from insurance carriers while maintaining stellar healthcare standards.

In your journey to enhance utilization management, you may find it beneficial to team up with a specialized provider. But how do you choose? Begin by assessing their industry experience and success stories; these are crucial indicators of competence.

Verify if they can deliver scalable solutions, as this shows adaptability in adjusting strategies according to changing needs or growth plans.

Next, evaluate the technical capabilities since automation is vital for efficient processes today. An ideal partner should offer cutting-edge tools along with expert human support. Also, scrutinize the quality monitoring system; an exhaustive audit mechanism suggests more reliable services. Lastly, consider communication practices; regular updates keep everyone on the same page, driving effectiveness.

By leveraging technology, Brundage Group optimizes utilization management. Our expertise ensures compliance with healthcare regulations and delivers top-notch patient care. With our solutions, you can see reduced costs and a more efficient system overall, as well as real-time consultation and data analysis for long-term strategy.

Utilization management is a pivotal method to ensure healthcare is delivered effectively and efficiently. When discussing utilization management, remember that it’s all about ensuring you provide the right care at the right time in an appropriate setting. This critical process involves evaluating proposed medical treatments for necessity before they happen, monitoring ongoing treatment to optimize its course, or even revising plans retrospectively after completion, always prioritizing the patient’s well-being.

Think of utilization management like gears within a larger system: hospitals, doctors, insurance companies—everyone gets involved for optimum results. Picture prospective reviews as pre-checks on recommended interventions or potential referrals, excluding emergency admission cases. Concurrent reviews step in mid-treatment, while retrospective ones appraise concluded procedures from various angles, such as suitability and efficacy.

Ultimately, this serves patients, informs educational tools, and aids negotiations between insurers and health institutions during contract talks.

By implementing effective utilization management approaches, healthcare teams can potentially transform patient care. Improved health outcomes become a reality as services are tailored to individual needs. Patients may be directed towards additional resources like case management or disease programs, resulting in optimized personal well-being.

Utilization management offers a blueprint for treatment plans and reduces cases of unnecessary procedures, leading to lower overall costs without compromising the quality of care. Adhering strictly to set protocols amplifies efficiency within the system, minimizing waste on needless tasks and allowing caregivers more time dedicated solely to patients.

Furthermore, administrative burdens can be reduced when guidelines are clearly defined. This facilitates less paperwork for medical providers and allows them to concentrate on tending to their patients. This leads to increased job satisfaction and reduces the chances of overworking and eventually succumbing to burnout, which has become commonplace among today’s practitioners.

All these benefits contribute to fostering mutual understanding between the provider and payer sides, ensuring smooth coordination, and reducing errors due to miscommunication. This elevates standards rightly deemed by regulatory bodies, aligned perfectly with justifying why utilization management holds such significance in contemporary healthcare settings besides conforming to modern research practices.

Utilization management consists of several elements, creating a system that ensures effective care for patients. Firstly, pre-certification plays a crucial role. In this process, medical professionals evaluate whether proposed treatments are justified before they start. This helps to avoid unnecessary or repetitive procedures.

Secondly comes concurrent review, monitoring ongoing treatment progress while monitoring resource use as and when needed during patient recovery phases. Concurrent reviews help identify any potential course corrections based on support level needs at different stages of healing.

Another significant aspect is discharge planning. It outlines criteria for completion and a planned exit from the facility after successful treatment completion, ultimately leading to cost-effective post-hospital care management without compromising quality standards in the interests of stakeholders, both hospitals and insurers.

Lastly, case coordination aims to assist multiple providers in managing their efforts while caring together through well-defined plans, fostering cooperation, and guaranteeing optimal results despite complex differences between individual patient cases.

Doctors’ participation in utilization management is essential, tasked with critically assessing patient needs, including gauging the appropriateness of care and the clinical necessity of services or treatments requested. Doctors contribute to utilization management by ensuring patients get appropriate treatment at the right time from suitable providers, all while keeping costs effective.

At its core, this process maintains high-quality healthcare service delivery, promotes safety, and avoids unnecessary expenses. Collaboration also matters significantly in utilization management. Medical providers will work closely with other professionals, such as case managers or nurses, to review measures implemented following evidence-based medicine practices, thus contributing towards optimizing health management strategies envisioned within utilization management programs.

Your actions also impact regulation compliance since medical practitioners’ assessments contribute substantially to defining the pathways followed during audits conducted under governmental guidelines, such as HEDIS and NCQA standards. The role is pivotal, aiming to establish an equilibrium between quality patient care and efficiency.

Striking a balance between quality care and cost containment is crucial in healthcare. Utilization management ensures resources are used efficiently without sacrificing the patient’s well-being. The utilization management process evaluates treatments for their long-term effectiveness, not just their immediate results, meaning decisions aren’t dictated by upfront costs alone but also consider future health outcomes.

Cost containment doesn’t mean reducing the quality of service due to budget constraints; instead, it ensures that the services provided align with best practices while remaining fiscally responsible. Physicians conduct rigorous assessments before starting treatment using evidence-based criteria from trusted sources like recognized medical societies or government agencies such as the Centers for Medicare and Medicaid Services.

Finally, another dimension of this delicate balance lies within pre-service reviews; scrutinizing proposed procedures beforehand helps prevent unnecessary denials or redundant or unnecessary interventions that may inflate expenses.

Technology plays a pivotal role in the application of utilization management today. Evidence-based software, electronic health records, and data analytics are increasingly leveraged to streamline utilization management processes. Initially, reviewing medical needs was manual work, but nowadays, artificial intelligence aids this process, significantly speeding up review times.

A revolutionary tool you might use is predictive modeling, which uses historical patient data to assess potential risks or outcomes. Machine learning algorithms can even identify trends and patterns within large datasets, making it easier for hospitals to target areas where intervention would benefit most. Telehealth services also integrate seamlessly with these systems, enabling remote monitoring of patients and ensuring their treatment plan aligns correctly with their healthcare coverage, thereby reducing unnecessary hospital visits.

Diverse tech applications like these certainly bring about an innovation-driven change in utilization management. Utilization management ensures the best use of healthcare resources for optimal patient outcomes. By evaluating the medical necessity, appropriateness, and efficiency of services, it fosters quality care at affordable costs, making it pivotal to modern-day healthcare systems.

This guide offers practical strategies for administrators eager to tackle these issues head-on with data-driven decision-making tools.

The strain on ICU capacity can significantly influence this period. Research indicates that a congested intensive care unit might lead to increased mortality rates among admitted patients.

Interestingly, hospitals categorized as ‘safety net’ establishments often exhibit poorer performances under Medicare’s value-based purchasing system than other types of hospitals. That could also affect their average duration of patient stays. Furthermore, emergency department crowding may consume more time and considerably extend your admission span in medical facilities.

Inadequate management or handling during peak hours potentially causes dangerous delays and adversely affects patient outcomes. Notably, too, are studies that suggest associations between lengthy boarding times in emergency departments and higher mortality rates post-admission. Such observations underline how aspects like overcrowding and resource availability directly contribute to fluctuating lengths of hospital stay.

Monitoring remains crucial as you navigate the length of stay. Data from nearly all leading medical institutions hint at a trend: decreases in LOS might be stalling or even rising slightly. Shining the spotlight on LOS brings several factors into focus.

Patient satisfaction measures seldom factor in LOS. Patients value tangible outcomes above the duration spent within hospital walls. Unless instructed to do so by administrators or payers, clinicians may ignore LOS. Despite warnings that prolonged stays increase risks, the evidence to back this is flimsy and nuanced by the severity of illness.

The role of academic medical centers comes under scrutiny with overflowing emergency departments and mounting pressure for costly expansions, a burden passed onto taxpayers, patients, and insurers alike, highlighting an urgent need for strategies beyond mere construction projects. Finally, there’s judiciousness about who needs admission. The potential impact here on lowering avoidable admissions could be significant, but it raises complex questions around diagnosis efficiency too.

Understanding and managing LOS requires multi-faceted approaches sensitive to patient needs and system pressures.

Shifting your focus to better bed management can revolutionize LOS. Making beds available when needed cranks up throughput, decreasing overall patient stay periods. Adopting best practices from other institutions and applying them in real-time scenarios can create a smoother transition.

Adopting technology also plays a significant role, as it facilitates easy access and sharing of health records amongst staff members, promoting efficient service delivery. Furthermore, consider reassessing discharge processes, where inefficiencies often go unnoticed. Ensuring proper planning and communication with patients regarding expected release times can ease bottlenecks that typically occur during peak hours.

Efficient scheduling of tests is another key area worth addressing, as it considerably reduces unnecessary waiting times, thereby effectively trimming the duration of hospital stays. Remember, though, involving front-line employees while developing strategic plans will increase their engagement levels; ultimately fuel improved results.

Managing efficiency in a healthcare setting plays a crucial role. Your focus should center on patient flow and the use of hospital resources. Consider reducing unnecessary wait times, improving organizational structures of care, hastening decision-making processes, and bolstering discharge planning initiatives with technology.

Efficiency can be further boosted by specific interventions that address clinical care improvements, such as early mobility programs for patients, and logistical factors, such as medication management systems to reduce pharmacy-related delays. Carefully designed workforce strategies also prove influential here; consider introducing multidisciplinary teams who can collaborate effectively towards improved workflows within your facility’s unique infrastructure constraints.

Remember, all measures taken should maintain an equilibrium between risk and outcome; efficient treatments shouldn’t compromise safety or thrust unexpected costs onto outpatients. The key is sustaining improvement while being mindful not to disadvantage those facing socio-economic hardships or complex medical needs.

Remember that every individual’s health journey is unique; what works for one might not work for another. Shorter lengths of stay may seem beneficial from an economic standpoint, but they could have potential drawbacks.

In some cases, premature discharges can lead to readmissions if a person isn’t fully healed. Conversely, extended hospitalization puts patients at risk of acquiring infections while potentially straining mental wellness since hospitals aren’t homelike environments. It becomes apparent then why striking a balance matters greatly in this scenario; neither rushing discharge nor delaying it unnecessarily aligns with providing optimal care or upholding patient safety standards.

Monitoring and adjusting lengths of stay needs careful consideration of the condition’s severity and personalized treatment plans. It shouldn’t only be viewed as a cost-saving exercise but also pivotal in enhancing overall healthcare quality.

Clinicians face several challenges in managing hospital length of stay. Data reveals that patient overcrowding, especially during peak times, makes it tough to allot critical care resources properly. This strain on ICU capacity can adversely impact the quality of care provided.

Also, an often unexpected issue is safety-net hospitals performing poorly under Medicaid’s value-based model compared to other hospitals, emerging as a cause for concern. Emergency department crowding bears mentioned here because it further complicates outcomes for admitted patients.

Finally, clinicians grapple daily with balancing efficient discharge strategies without compromising patient health or risking potential readmission. Even though researchers are striving hard to find effective solutions and improvements continue to be made gradually, these issues remain significant obstacles affecting optimal management practices related to hospital stay durations.

Ultimately, managing hospital length of stay is a balancing act. You have to weigh quality care against cost-effectiveness. Reducing prolonged stays isn’t only about revenue; it’s key for optimizing patient satisfaction outcomes.

Learn about the specific outcomes of the emergency department pilot program during Dr. Timothy Brundage’s session at the ABQAURP Annual HCQ&PS Conference, “Optimizing Coordination Among Mid-Revenue Cycle Stakeholders,” on Friday, October 7, 2022, at 4:30 p.m. Read the article on the ABQAURP website.

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Across many hospital systems, the demand for patient beds outweighs the supply. This can lead to a plethora of problems, including surgery cancellations, declining patient and staff satisfaction, and increased length of stay for patients in every setting, e.g., inpatient, emergency department, etc. Further, when capacity is a problem, hospital leadership spends unnecessary time addressing capacity management issues—valuable time that cannot be regained.

Hospital leadership would agree there is a need to develop a strategic process to manage bed capacity. Ideally, a plan would be developed through collaboration of hospital leadership and hospital-wide staff, with solutions that focus on maintaining or improving quality and outcomes. From a staffing perspective, when staff efficiency increases, employees are less burdened with managing capacity issues and more focused on patient care. For patients, having a bed available in the right setting makes them feel valued and cared for, resulting in a positive effect on patient satisfaction and outcomes.

Emergency Department (ED) crowding is not a problem that exclusively impacts the ED, but rather one that impacts all patient care areas and requires hospital-wide solutions. Long wait times can lead to potential safety events and dissatisfaction with overall care. Addressing ED crowding should be at the forefront of organizational improvement efforts, as it is costly and compromises care quality and public perception and trust.

Brundage Group embarked on an ambitious pilot project to solve patient throughput issues by targeting patients with hospitalization orders who remained in the ED awaiting bed assignment. Integral to the project was a dedicated Physician Advisor in the ED to help optimize workflows, admission, and discharge processes. The goals of the pilot were to confirm accurate level of care orders at the time of admission; reduce avoidable admissions; and improve communication between the ED physician, admitting hospitalist, and ED case manager.

The ED project was a collaboration between Brundage Group and a Level 1 Trauma Center that is one of the largest hospitals in Florida. A hospital representative will co-present the session, Optimizing Coordination Among Mid-Revenue Cycle Stakeholders, along with Physician Advisor, Dr. Timothy Brundage, during ABQAURP’s Annual Health Care Quality & Patient Safety Conference.

The project team included a Physician Advisor as the dedicated resource for the pilot; a utilization management nurse to create a UM presence that did not previously exist in the process; an ED care coordinator/case manager (CM), who refocused efforts to prioritize ED discharge planning; and an ED social worker (SW), who remained focused on serving ED patients.

The team developed a process to target “boarder” patients – a patient who requires care beyond ED services but remains in the ED because there is no hospital bed available. As part of the pilot, the project team would meet in the ED at multiple standing times throughout the day to review all boarder patients.

To help encourage efficient patient throughput, the team leveraged case management services. While CM is required for inpatient, the team realized the CM role could also be applied in the ED to help support the patient discharge process as appropriate while enabling the ED to treat a greater capacity of patients. During the frequent meetups, the team leveraged these dedicated ED CM/SW teams to identify patients for whom referrals could be obtained for additional services allowing discharge directly from the ED.

Level of care determinations had a two-prong approach. Led by the Physician Advisor, the boarder round team helped to ensure appropriate level of care status and would contact the attending physician if a status order needed correction. Additionally, UM nurses were tasked with reviewing ED cases outside of boarder rounds, referring identified cases directly to the dedicated ED Physician Advisor. A key element was the physical placement of the UM nurse within the ED to directly communicate with ED physicians as quickly as possible to support accurate status determination and maximize real-time communication.

The results of the pilot program showed significant reduction in avoidable admissions, validated patient status determinations, and a change in the ED physician culture, becoming more confident that discharge planning could be safe and efficient with appropriate support from the CM/SW role.

The outcomes underscored the need for a dedicated ED Physician Advisor to add credibility to the project and to optimize the discharge process. Further, reviewing a case for appropriate level of care early in the ED stay improved the accuracy of level of care determinations and ultimately improved hospital capacity management. The pilot project also spurred a change in ED physician culture that extended to the general medical staff through education and Physician Advisor engagement.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

“Upcoding” remains a common mechanism of improper payments.

“Healthcare compliance is the process of following rules, regulations and laws that relate to healthcare practices,” according to the PowerDMS Policy Learning Center. Although all healthcare organizations have a compliance department, how the clinical documentation integrity (CDI) department interacts with compliance and supports practices compliant with Centers for Medicare & Medicaid Services (CMS) regulations varies across health systems. The purpose of a compliance program is to prevent, detect, and correct non-compliance to avoid fraud, waste, and abuse.

According to the U.S. Department of Health and Human Services (HHS), some healthcare entities pose a heightened risk to the financial security of Medicare due to the volume of improper payments they incur. Healthcare organizations have a duty to submit proper claims to CMS; however, “upcoding” remains a common mechanism of improper payments. Because compliance is the responsibility of everyone employed by the health system, CDI leadership should be actively engaged in monitoring CMS claims data for potential overpayments that could represent simple errors or process issues resulting in institutional non-compliance. In particular, CDI departments should be gatekeepers meant to avoid “billing for services at a level or complexity higher than services actually provided or documented in the medical record,” according to CMS.

An overpayment is defined by Medicare as one that “exceeds regulation and statute properly payable amounts.” Medicare overpayments can occur due to “incorrect coding and/or insufficient documentation,” both of which should be monitored by CDI and coding leadership. Healthcare entities have 60 days from overpayment identification to report and return a self-identified overpayment to Medicare. Reporting of an overpayment should include a written explanation for the overpayment, e.g., coding error, failure to follow organizational billing practices, etc. The concept of “identification” is broadly applied, as the rule states that this means when a person has or “should have, through the exercise of reasonable diligence” determined an overpayment.

Misusing codes on a claim, such as upcoding (when a provider assigns an inaccurate billing code to a medical procedure or treatment to increase reimbursement) and coding errors are examples of Medicare abuse if the incorrect coding or billing practices are not widespread practices, in which case it could be an example of fraud. CDI and coding professionals are both subject to the federal civil False Claims Act (FCA):

“The civil FCA imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim to the Federal Government. The terms ‘knowing’ and ‘knowingly’ mean a person has actual knowledge of the information or acts in deliberate ignorance or reckless disregard of the truth or falsity of the information related to the claim. No specific intent to defraud is required to violate the civil FCA.”

CMS has a variety of tools to monitor inaccurate payments, including the Comprehensive Error Rate Testing (CERT) Program, Medicare Administrative Contractors (MACs), and the Recovery Auditors. According to CMS, the CERT program reviews a statistically valid stratified random sample of Medicare fee-for-service (FFS) claims to determine if they were paid properly under Medicare coverage, coding, and payment rules. CERT findings create the framework for MAC audits and those performed by Recovery Auditors. While CERT leverages a random sample of claims, the Program for Evaluating Payment Patterns Electronic Report (PEPPER) data provides hospital-specific Medicare claims data. Target areas included in PEPPER were identified by Recovery Auditors and MACs, and are updated periodically.

“PEPPER is an electronic report that provides provider-specific Medicare data statistics for discharges/services vulnerable to improper payments. PEPPER cannot be used to identify the presence of payment errors, but it can be used as a guide for auditing and monitoring efforts to help providers identify and prevent payment errors.”

If you manage a CDI or coding department, you should be reviewing your PEPPER data on a quarterly basis; however, the national download rate is currently at 62 percent. Failure to monitor Medicare claims data included in PEPPER can be an example of “deliberate ignorance or reckless disregard,” according to ACDIS, if your organization is an outlier. Although PEPPER data is not specifically distributed to Recovery Auditors or MACs, both of these Medicare contractors have the ability to request charts related to PEPPER target areas, and have sophisticated data mining techniques to identify outliers.

PEPPER target areas are constructed as a ratio. The numerator includes discharges identified from paid Medicare claims per CMS fiscal year (i.e., October to September) quarter that are identified as potentially problematic because they are likely to be miscoded or result in medically unnecessary services. The denominator is the larger reference group that includes the numerator.

For this article, our focus is coding target areas that include:

• Stroke Intracranial Hemorrhage;
• Respiratory Infections;
• Simple Pneumonia;
• Septicemia;
• Unrelated OR Procedures;
• Medical DRGs with CC or MCC;
• Surgical DRGs with CC or MCC;
• Single CC or MCC;
• Severe Malnutrition;
• Excisional Debridement;
• Ventilator Support; and
• Emergency Department Evaluation and Management Visits.

Each hospital’s ratio is compared to other hospitals at the state, MAC jurisdiction, and national levels, resulting in a ranking by volume percentage. PEPPER data uses the high outlier threshold of the 80th percentile and a low outlier threshold of the 20th percentile. If the percentage of paid Medicare claims for the specific target area ranks at the 80th percentile or above, the organization is considered a high outlier for that target area. In other words, the percentage range for a particular target area may be from 20 to 75 percent. The 80th percentile may result in all those hospitals with a target area ratio of 68 percent or higher. The ratios among all hospitals and the 80th percentile cutoff will vary from quarter to quarter.

If you are new to PEPPER and integrating a compliance focus into your CDI or coding practices, a good place to start is the National High Outlier Ranking Report. This page of PEPPER data will have red if your organization is a high outlier in any target area across the most recently reported 12 quarters of data, as well as the total number of times your organization was a high outlier for each target area. If your organization happens to be a high outlier for any coding target area, that does not necessarily mean there is a compliance issue. A best practice is to investigate why your organization is an outlier by sampling claims and reviewing documentation to validate the assigned codes and billing. Ask yourself, does it make sense for your hospital to be among the top 20 percent of all hospitals for that particular target area?

CDI departments are increasingly renaming the “I” from “improvement” to “integrity.” Integrity is defined as “the quality of being honest and having strong moral principles.” Reviewing PEPPER data is a way for CDI and coding managers to identify areas that may be vulnerable to overpayment. If outliers exist, investigate the associated claims to validate the coding and billing. If coding or billing errors occurred, determine the cause(s) of the errors, e.g., human error or process issues, and look for ways to prevent future non-compliant coding and billing practices. Even if your organization is not an outlier or the internal investigation does not reveal the potential for overpayment, CDI and coding leadership should ensure there are safeguards in place to prevent non-compliance, and monitor staff adherence to those processes.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

As a former manager of clinical documentation integrity (CDI) and utilization review (UR) at an academic medical center, my focus was on understanding all possible sources of revenue leakage. At that time, the UR staff focused on activities that demonstrated a patient’s medical necessity, as defined by a variety of payers, but often required application of InterQual criteria, while the CDI team focused on capturing patient acuity to support accurate reimbursement under the Inpatient Prospective Payment System (IPPS) and other DRG payers.

However, we had a blind spot – before medical necessity can be supported and diagnoses reported on a claim, the services provided must first be covered by the payer. The approval process is somewhat straightforward, when it comes to commercial payers, as it involves prior authorizations (or precertification) – and most healthcare organizations have staff dedicated to obtaining these authorizations. But this is less well-known when it comes to Medicare beneficiaries.

Medicare coverage polices specify which items and services are covered under the Medicare program, and under which circumstances – such as when required specific clinical criteria are met. We see some outpatient CDI efforts supporting medical necessity (e.g., ensuring that the right diagnosis codes are included with imaging or injections), but it is far less common in the inpatient setting, where healthcare is much more expensive. When specific clinical criteria must be met to support Medicare coverage, it is often outlined in National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). The Centers for Medicare & Medicaid Services (CMS) states that “services must meet specific medical necessity requirements in the statute, regulations, manuals, and specific medical necessity criteria defined by National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), if any apply to the reported service. For every service you bill, you must indicate the specific sign, symptom, or patient complaint that makes the service reasonable and necessary.”

Now, not all services have NCDs or LCDs, but if there is one associated with a service, the medical necessity must be demonstrated with specific clinical criteria. Some services are specialized (e.g., transcatheter aortic valve replacement, or TAVR), and there may be a dedicated team within your organization to serve these types of patients – and they may be responsible for demonstrating the service as covered, while other, less specialized procedures (e.g., implantable cardioverter defibrillators (ICDs) or cardiac pacemakers) may also have associated NCDs. The NCD for ICDs has only been effective since 2018, but the NCD for single-chamber cardiac pacemakers has been effective since 1983.

An example of criteria that must be included for a single-chamber cardiac pacemaker to be covered are the following diagnoses, which must be “chronic or recurrent and not due to transient causes such as acute myocardial infarction, drug toxicity, or electrolyte imbalance:”

• Acquired complete (also referred to as third-degree) AV heart block;
• Congenital complete heart block with severe bradycardia (in relation to age), or significant physiological deficits or significant symptoms due to the bradycardia;
• Second-degree AV heart block of Type II (i.e., no progressive prolongation of P-R interval prior to each blocked beat. P-R interval indicates the time taken for an impulse to travel from the atria to the ventricles on an electrocardiogram);
• Second-degree AV heart block of Type I (i.e., progressive prolongation of P-R interval prior to each blocked beat) with significant symptoms due to hemodynamic instability associated with the heart block; and
• Sinus bradycardia associated with major symptoms (e.g., syncope, seizures, congestive heart failure), or substantial sinus bradycardia (heart rate less than 50) associated with dizziness or confusion. The correlation between symptoms and bradycardia must be documented, or the symptoms must be clearly attributable to the bradycardia, rather than to some other cause.

NCDs are established criteria for when a service is not covered by Medicare, for example regarding the single-chamber pacemaker: “conditions which, although used by some physicians as a basis for permanent cardiac pacing, are considered unsupported by adequate evidence of benefit and therefore should not generally be considered appropriate uses for single-chamber pacemakers in the absence of the above indications.” These include:

1. Syncope of undetermined cause;
2. Sinus bradycardia without significant symptoms;
3. Sino-atrial block or sinus arrest without significant symptoms;
4. Prolonged P-R intervals with atrial fibrillation (without third-degree AV block) or with other causes of transient ventricular pause;
5. Bradycardia during sleep;
6. Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent AV block);
7. Asymptomatic second-degree AV block of Type I, unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His bundle (a component of the electrical conduction system of the heart); and
8. Asymptomatic bradycardia in post-MI patients about to initiate long-term beta-blocker drug therapy (effective Oct. 1, 2001).

LCDs are similar to NCDs, but defined by the Social Security Act as a “a determination by a fiscal intermediary or a carrier under Part A or Part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis.” General information about LCDs can be found in Chapter 13 of the Medicare Program Integrity Manual. However, specific LCDs would be available from the applicable Medicare Administrative Contractor (MAC), or there is a searchable database for both NCDs and LCDs at https://www.cms.gov/medicare-coverage-database/new-search/search.aspx. An example of an LCD is cardiac catheterization and coronary angiography, which is currently effective for two contractors. This LCD outlines indications supporting a right, left, or both a right and left heart catheterization, as well as limitations (such as when a right heart catherization or left heart catheterization is not considered medically necessary).

As you can see from the NCD example above, these criteria don’t really fall into typical CDI or UM work, but could result in significant lost revenue if not provided when necessary. There is a component of both departments, as there is often a requirement for specific diagnoses to be present, often with an associated ICD-10-CM code (of note, CMS is still in the process of converting ICD-9-CM codes to ICD-10-CM/PCS codes for some NCDs and LCDs), as well as supporting clinical criteria so the diagnosis can be clinically validated. To see an example of what updated codes are included in the NCD for ICDs, effective July 6, 2021, go online to www.cms.gov/files/document/r10635CP.pdf. This document provides instructions to the MACs when processing claims for ICDs to ensure that NCD criteria are met by listing what ICD-10-CM and ICD-10-PCS codes should be present on the claim.

As CDI departments continue to grow, some are venturing out into to new areas like covered services, as defined by NCDs and LCDs, to avoid service denials. Unlike DRG changes, these types of denials often result in no payment, rather than reduced payment, which can be costly if it involves a procedure and the cost cannot be shifted to the Medicare beneficiary if due diligence was not completed by the organization. This is not an area that can be easily integrated in the CDI workflow, so it would likely require dedicated CDI staff with knowledge and understanding of where to find NCDs/LCDs and how to apply the criteria correctly.

By: Timothy Brundage, MD, CCDS, Medical Director & CEO of Brundage Group

The diagnosis of Healthcare-Associated Pneumonia (HCAP) is clinically out of date and does not effectively code. The diagnosis of HCAP maps to the DRG for simple pneumonia. Simple pneumonia is a diagnosis that can often be treated in the outpatient setting. HCAP clearly does not fit into this DRG grouping, so physicians should update their clinical practice and their documentation.

Here’s why physicians should not document Healthcare-Associated Pneumonia:

• The diagnosis of HCAP is clinically out of date.
• HCAP does not code effectively.
• The use of HCAP as a diagnosis is discouraged by the Infectious Diseases Society of America.
• HCAP is the wrong diagnosis!

Oral antibiotics are extremely effective in treating simple pneumonia. If a patient truly demonstrates medical necessity for inpatient admission to the hospital, the patient likely has either complex pneumonia or sepsis. (Severe) sepsis is now defined as organ dysfunction due to the infectious process, however, physicians often fail to link the pneumonia with the organ dysfunction. Physicians should update their documentation practices.

As an example: a patient is admitted to the hospital with the diagnoses of pneumonia and acute kidney injury (AKI). Effective documentation would link the conditions as “pneumonia causing AKI.” When pneumonia causes the AKI, then the physician should properly diagnose the patient with sepsis or severe sepsis, explicitly linking the organ dysfunction to the infection.

It is exceedingly common for physicians to admit patients to the hospital and treat them with very aggressive antibiotics without adequately documenting a diagnosis to support the reason why “big-gun” antibiotics are necessary. Physicians should allow their choice of antibiotics to drive their documentation.

For example, the following language is clinically appropriate and codes effectively.

• Zosyn, to treat suspected gram negative (pseudomonas) pneumonia
• Vancomycin, to treat suspected MRSA pneumonia
• Zosyn, Clindamycin or Flagyl, to treat suspected aspiration pneumonia

If hospitalists are scrutinized by length of stay metrics, they should understand that expected length of stay (LOS) is calculated using the documented diagnoses. Suspected gram-negative pneumonia creates a longer expected LOS in the hospital than does simple pneumonia.

Our physician-to-physician education creates savvy documenters who understand how to use coding-based language to demonstrate medical necessity and accurately calculate the DRG. With our support, physicians can learn to document effectively to capture the patient’s severity of illness to support the DRG and quality metrics.

Learn more about our services.

The National Association of Healthcare Revenue Integrity (NAHRI) recently asked our medical director, Dr. Tim Brundage, for his insight on Medicare Advantage denials. Click to read the complete NAHRI Journal article, “Take control of Medicare Advantage denial challenges”.

“It isn’t surprising that MAOs are looking to make a profit; after all, they are private companies. But the implications of denying or delaying medically necessary treatment to cancer patients while offering benefits such as high-tech fitness trackers raises reasonable concerns about how some MAOs are using federal money, says Timothy Brundage, MD, CCDS, medical director of The Brundage Group in St. Petersburg, Florida. “They’re promising all the bells and whistles. The only way you can provide bells and whistles is if you’re actually saving cost, and the way to save cost is to have the care of the patient be lower than the expected cost of caring for the patient,” he points out.

In theory, MAOs will keep patients healthy by encouraging them to make use of lower-cost outpatient services such as regular primary care checkups. In turn, MAOs are encouraged to keep patients healthy and out of the hospital through risk-sharing and capitated payments. However, as the OIG report pointed out, that can incentivize MAOs to deny or delay medically necessary care that can only be provided in a hospital. “The biggest-ticket item that you have as a risk dollar is an inpatient hospitalization. That’s a super-expensive place to receive care, and obviously that patient is very sick if they get admitted to the hospital,” Brundage says. “The managed Medicare folks do everything in their power to keep the patient in observation or outpatient so they’re caring for their patient at the lowest cost possible.”

By: Dr. Timothy Brundage

I just returned from the ACPA National Physician Advisor Conference where I met with physicians who truly care about providing support to their hospitals.

As a key takeaway from the conference, I’d like to encourage Physician Advisors around the country to break down the silos that exist within hospital organizations. Physician advisors should be focused on much more than patient status assignment; they should be looking at the chart from a global perspective to accurately reflect the care provided. This perspective should supersede the utilization review department, the quality department and the CDI department.

The Physician Advisor should examine the chart to ensure that medical necessity is present while also ensuring the documentation supports accurate code assignment and the timeliness of the documentation supports the quality of care provided.

Only diagnoses that are captured Present On Admission (POA = Y or W) are used by Medicare to risk adjust expected mortality. The Physician Advisor should be keenly aware that mortality observed to expected rates are publicly reported. Our hospitals should provide the community with high-quality care that should be reflected as such in the metrics.

The Physician Advisor should be able to take a case review for medical necessity, which contains the documentation of cystitis and acute kidney injury with an acutely elevated Cr of 2, for example, and understand that this may or may not support inpatient status. If the Physician Advisor understands the global care provided to the patient, he or she should immediately work with the attending physician to document more effectively. If the acute kidney injury is explicitly linked to the cystitis, then the clinician should contemplate the diagnosis of severe sepsis based on SOFA.

This will immediately improve documentation that may potentially support inpatient status, support the appropriate DRG assignment to track expected resource consumption and track to the accurate expected mortality.  The utilization management team is supported, the CDI team is supported, and the quality team is supported. Most important, the accurate picture of the patient is reported—and the patient is supported!

The Sepsis-3 JAMA article published in 2016 reports a 10% expected mortality when diagnosing (severe) sepsis using the SOFA criteria.  This patient is sick, even more so than you may believe.

The role of a Physician Advisor is to support the clinician who is caring for the patient. The patient needs high-quality care and the clinician needs to be able to provide the care in the appropriate setting while also demonstrating that he or she is providing high-quality care to the community.

Physician Advisors should be breaking down the silos within hospitals to advocate for global care and global tracking of high-quality care.  They should get involved with the CDI team and the quality team, and make sure they are working with the utilization review team in a coordinated fashion.

It is not uncommon for me to go into a hospital and see the utilization review, CDI and quality teams working completely independently from one another, with very little communication.

The role of the Physician Advisor is to lead the team toward the accurate portrayal and status of the patient, as well as the appropriate tracking of the quality of care that physicians are providing to the community.

And I almost forgot to mention—this will also reduce the risk of denial if audited.