Navigating the Complexities of Outpatient in a Bed (OPIB)

Navigating the Complexities of Outpatient in a Bed (OPIB)

The implementation of outpatient in a bed (OPIB) classifications in hospital settings presents unique challenges, particularly regarding billing, patient care, and regulatory compliance. These challenges may vary across hospitals, depending on electronic medical record (EMR) classifications and internal hospital bylaws or policy guidelines for managing this population.

With the looming continued aging of baby boomers requiring more healthcare services and increased social awareness of patient healthcare needs, compounded by provider moral distress, and the administrative pressures of doing more with less, social hospitalizations are continuing to rise.

Understanding and Documenting OPIB

OPIB is defined as an outpatient medical record designation that identifies a patient bedded in the hospital who initially or no longer warrants medically necessary services, from a billing perspective. These patients are often placed in the hospital setting because their social situation leaves them with no other alternative, or they remain in the hospital until an alternative location can be secured, despite the completion of observation services. To date, the Centers for Medicare & Medicaid Services (CMS) has not recognized this level-of-care designation in hospitals.

Since these patients are outpatients, the full admission requirements for hospital inpatients are not required. Thus, documentation requirements should fall to the hospital bylaws and internal policies and procedures.

Extended Observation versus OPIB

It is rare and unusual for a patient receiving observation services to remain in the hospital for a prolonged period. Since observation is a service, the review of medically necessary observation services is either completed, and the patient’s continued stay is due to social considerations, or the patient’s condition warrants hospital admission. For patients who remain purely for custodial reasons, they should be notified that observation services have ended.

There should also be a clear transition documented in the EMR, with an end to the observation services ordered or a change in the EMR encounter type to indicate that observation hours have been completed. This will help avoid confusion regarding any changes or decrease in services due to the patient’s lack of medical necessity.

Key Considerations for OPIB Classification
  • Defining Outpatient Classification: Clearly define what constitutes an outpatient classification. This involves setting clear criteria and guidelines for when a patient is placed in the hospital for an OPIB designation. Consider incorporating this into the patient classification guidelines to guide the utilization review and physician advisor team in reviewing these patients.
  • Documentation Requirements: If this designation is a part of your hospital’s EMR, then it will be helpful to ensure that policies and procedures reflect the standards for provider and clinical staff documentation.   
  • Acceptance and Decision Tree: Develop an acceptance or decision tree protocol for determining when a patient qualifies for OPIB. This protocol should outline specific criteria and decision points for healthcare providers to ensure that medical necessity does not exist or has ceased. This decision tree should also include review of alternative locations that may be better-suited for these individuals, rather than the hospital.
  • Patient Communication: Inform patients about their OPIB classification, including how it affects their care and billing. Clear communication helps manage patient expectations and reduces confusion regarding their treatment plan.
  • Billing and Ancillary Services: Determine if and how the hospital plans to charge for services rendered to OPIB patients, particularly ancillary/professional services. Establish transparent billing practices to ensure that patients are aware of potential costs. Should the hospital determine that they are not going to bill the patients, it will be key to maintain appropriate reporting (see Dr. Ronald Hirsch’s comments and articles on A2970).
  • Internal Tracking and Reporting: Implement a system to track OPIB cases internally. This tracking is crucial for future prevention strategies, charity reporting, and maintaining compliance with regulatory standards.

Avoiding Social Admissions

To prevent social admissions, consider leveraging agreements with hospital-owned or community partners. This might include post-acute care facilities, community housing settings, or other properties the hospital owns or partners with. Establishing a fast track from ED to post-acute care may be a lower-cost alternative to taking up medically necessary resources in the hospital (which is likely a whole other article as to why the hospital is not the best fit for social care).

Effectively managing OPIB classifications requires clear definitions, documentation, and proactive communication with patients. Acknowledging the new norm and creating internal guidelines for addressing this population, hospitals can navigate the complexities of OPIB, maintain regulatory compliance, and provide appropriate care while managing resources efficiently.

Properly implemented, these strategies will help avoid legal challenges and improve overall patient satisfaction and outcomes.

Programming note:
Listen to Tiffany Ferguson report this story live on Talk Ten Tuesday with Chuck Buck and Dr. Erica Remer, 10 Eastern.

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Tiffany Ferguson, LMSW, CMAC, ACM

Tiffany Ferguson is CEO of Phoenix Medical Management, Inc., the care management company. Tiffany serves on the ACPA Observation Subcommittee. Tiffany is a contributor to RACmonitor, Case Management Monthly, and commentator for Finally Friday. After practicing as a hospital social worker, she went on to serve as Director of Case Management and quickly assumed responsibilities in system level leadership roles for Health and Care Management and c-level responsibility for a large employed medical group. Tiffany received her MSW at UCLA. She is a licensed social worker, ACM, and CMAC certified.

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