Appeals, Knee Surgery, and IV Fluids in the News

With a week off, I have much to report today to catch up. First, many of you may have heard or read that Medicare has finalized a new appeal process for Medicare fee-for-service beneficiaries. Before you panic, it is a very limited opportunity only for a very tiny class of patients, those who have Part A and not Part B, who are admitted as an inpatient, but then have their status changed to outpatient and receive observation services.

The other group of patients are those with traditional Medicare, who are admitted as an inpatient, have their status changed to outpatient, receive observation services, and then stay a total of three or more days. Since these patients stay three days but have no qualifying stay for Part A coverage of a nursing-home stay, they will have the right to appeal their change from Part A to Part B.

The Centers for Medicare & Medicaid Services (CMS) has an official notification form, the Medicare Change of Status Notice(MCSN), at the Office of Management and Budget for approval – and it appears to be rather simple, unlike the Medicare Outpatient Observation Notice (MOON), so even when needed, it should not be onerous. We don’t anticipate this process starting until early 2025, so for now, sit back, keep listening to Monitor Mondays and reading RACmonitor eNews, and wait for more instruction from CMS.

Second, a loyal reader sent me a denial received from the Comprehensive Error Rate Testing (CERT) contractor of a total knee arthroplasty patient who was admitted as an inpatient and stayed two days as inpatient. The patient had significant comorbidities and required in-hospital monitoring for those two days. This was anticipated, and the physician admitted the patient as an inpatient preoperatively and documented their decision process.

The contractor denied the inpatient admission, stating that the patient “did not develop any complications which warranted inpatient admission.” As many would expect, I was furious reading this, and not only did I provide the person the pertinent references for an appeal, but also felt compelled to write to CMS and complain about the poor performance of their well-paid contractors. The provider also contacted CMS and provided the claim information so CMS could pull the actual file and investigate. If we get a resolution, I will report on it.

Moving on, I don’t know if any of you follow me on LinkedIn, but if so, you may have read my rant about managed care payers denying admission and hospital care for patients who do not meet commercial criteria because the rate of their intravenous fluids is not high enough. Normally, I would argue this is their right to strictly use criteria, if your contract allows that, but we are in the middle of a national shortage of intravenous fluids, wherein patients are having surgeries canceled and other care deferred because of this.

As a result, physicians have become very judicious in their use of intravenous fluids, and hoping that a lower rate of fluids plus oral hydration will suffice. The payers are heartlessly denying payment because that criteria rate of fluid was not being ordered. This is absolutely inappropriate. There is a national crisis that is affecting hospitals everywhere.

The managed care payers should not be using commercial criteria inappropriately and denying payment when physicians and hospitals are doing everything they can to adjust. My message to managed care is this: just stop these denials. Commercial criteria are guidelines, not lines in the sand, and a national shortage of intravenous fluids should be serious enough for you to realize that, as always, a patient can require hospital care even if not every checkbox is checked.

Finally, all of you are invited to attend an American College of Physicians Advisors Town Hall that will take place a week from today; I will be moderating. It is open to all, it is free, and you can register at ACPadvisors.org. We will be discussing the optimal relationship between physician advisors and case management staff. Hope to see you there.

Programming note:

Listen to Dr. Ronald Hirsch on the long-running Internet radio broadcast Monitor Mondays as he makes his Monday rounds, sponsored by R1-RCM with Chuck Buck.