All Healed Up with Nowhere to Go

All Healed Up with Nowhere to Go

On the June 5 edition of Monitor Mondays and in a recent RACmonitor news article, Dr. Bonny Olney from R1 RCM spoke about those patients who are stuck in the hospital without medical necessity, but also without anywhere to go. It’s happening everywhere, for many reasons. It is rare to find a hospital that is not boarding patients in the ED due to individuals in inpatient beds who cannot go anywhere due to lack of post-acute resources.

I don’t have a solution, but I will note that the American Hospital Association (AHA) has been talking to the Centers for Medicare & Medicaid Services (CMS) about establishing a per-diem payment to hospitals caring for such patients. Will that go anywhere? We can only hope so, but you might want to think about how your hospital knows which patients are there for medically necessary care and which aren’t. Are you using the appropriate occurrence span codes? Can you determine which observation hours are not medically necessary? Well, it just so happens that I discussed how you can do just that during my RACmonitor webcast.

In other happenings, there have been several speakers talking and writing about about the return of the three-day inpatient requirement for patients to get their Part A skilled nursing facility (SNF) benefit. I often hear that the patient must meet inpatient criteria for every one of those three days to count. But that’s not true.

First, CMS does not have any inpatient criteria; they have the two-midnight rule. More importantly, the Manual states that each inpatient admission must meet the requirements of the two-midnight rule, but unless the subsequent days represent a substantial departure from standard medical practice, the patient can access their Part A SNF benefit. What does that mean? Well, if the physician note says “keep one more day for SNF,” then that’s a substantial departure. But “keep one more day for monitoring,” while potentially not representing unambiguous need for ongoing hospital care, would allow that day to be counted.

Please keep that in mind as you navigate the three-day SNF rule, which was adopted in 1965. And remember, everyone knows that this rule has absolutely no applicability in 2023, but changing it would require Congress to pass a law – and despite multiple organizations lobbying Congress and educating CMS for years, we have seen no movement.

A few weeks ago I wrote a RACmonitor news article about the new CMS inpatient rehabilitation facility (IFR) prior authorization program. And if you read it, you may also have wondered about the data I presented. CMS data indicates that Texas, with about 2.3 million traditional Medicare beneficiaries, had over 63,000 IRF admissions in 2021 – but California, with over 3.4 million Medicare beneficiaries, had just over 19,000 IRF admissions. Texas has 141 IRFs, and California has 87. Is this overuse in Texas? Is this undersupply in California? Are there just more patients in Texas requiring IRF care? I have no clue, but if any of you understand this, please tell me.

Last week I saw a denial by a payer of a cardiac procedure that was approved as inpatient, but for a patient who went home from the recovery room. Why was it denied? The patient never occupied an inpatient bed. What devious methods to avoid payment will payers invent next? It’s lucky I inherited my mother’s excellent hair genes, or I would have been bald long ago from puling out my hair dealing with these insane and incomprehensible rules that do nothing but increase the height of hurdles to appropriate payment.

Finally, on LinkedIn last week someone posted about a colleague: a director of nursing at a U.S. hospital, who was on vacation in Costa Rica. A tree fell on her, causing a severe spinal-cord injury. Her friends were trying to raise money to get her transported back to the U.S.

I was in attendance at a conference several years ago where Eric Bergman, RN recommended to never leave the country without buying travel insurance with coverage for medical evacuation. These policies are quite reasonably priced. If you have international travel planned this summer, go right now and buy a comprehensive policy. You can only hope you are “throwing away your money” and never need it – but if you do need it, it might be money that might literally save your life.

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Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, and the National Association of Healthcare Revenue Integrity, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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