Not Just AI will Hallucinate Answers

If you listened to Monitor Mondays last week, you heard me talk about how artificial intelligence (AI) can make up answers and provide inaccurate information. And ever since, it is as if the AI overlords heard me and made sure I got several examples of humans making things up, to show that humans are no better than AI.

First, Tiffany Ferguson sent me slides from a presentation by one of the Medicare Administrative Contractors (MACs) on Part A Medicare. The slides contained several errors. I’ll start with the petty one: on one slide they use the abbreviation HHA, which we know designates a home health agency. But when they use it, they note that it stands for home health “association.” I am sure that advocacy organizations for home care agencies do not bill Medicare for services.

But much more offensive to me and Tiffany is that when discussing admission status, they indicated that there are two only options – inpatient and observation. Yes, you all know that observation is a service, not a status. They provided no information on how to status a patient having outpatient surgery, which we all know would be simply outpatient status. For clarity, there are two statuses, but they are inpatient and outpatient.

They also use a slide about services separately payable during an inpatient admission, and indicate correctly that the pneumococcal vaccine is eligible. But so are flu shots, and with fall rapidly approaching, why wouldn’t they mention that vaccine?

The next human error was relayed to me via an email from a case manager who said her hospital was currently being invaded by consultants – from a national organization that has its hands in every aspect of medical care – who were hired to improve operations, and of course, lower length of stay (don’t get me started on LOS!) This hospital had a Medicare inpatient who was transferring to an inpatient rehabilitation facility (IRF), and one of the expert consultants insisted that the patient receive a copy of their signed Important Message from Medicare (IMM) prior to transfer. The case manager knew this was wrong, so she contacted me. And of course, I provided her proof, both in the Medicare Manual and in an email from the Centers for Medicare & Medicaid Services (CMS) confirming that inpatient-to-inpatient transfers, even from acute care to an IRF or a long-term acute-care hospital (LTACH), do not get the follow-up copy of the IMM.

The next misinformation event came directly from Medicare. As many of you may know, with traditional Medicare, if a patient passes two necessary midnights in the hospital, meeting the benchmark, an inpatient order can be written even if the patient is going to be discharged soon thereafter. And we all know that Medicare Advantage (MA) plans must follow the Two-Midnight Rule, including recognizing the two-midnight benchmark. But does that mean they must allow for that inpatient order on the day of discharge?

Well, in an attempt to get an answer, I used the CMS Part C question portal. And when one enters a question there, it provides a list of questions that might be similar, ostensibly to save time for everyone.

One of the suggested questions was “Does the Two-Midnight Rule apply to Medicare Advantage plans?” Well, I knew that answer, but wanted to see what the FAQ would say, so I clicked it. And the answer was “Section 10.2 of chapter 4 of the Medicare Managed Care Manual states that ‘MA plans need not follow original Medicare claims processing procedures.’ Therefore, MA plans are not required to follow the Two-Midnight Rule with regard to contracted providers.

The contract between the MA plan and the hospital provider contains the specific terms regarding inpatient hospital admissions.”

Wait, what? Of all sites we should be able to trust, an actual CMS site should be among them. So once again, “trust but verify” is the key, and it even applies to CMS writings. And as Cate Brantley says, “at least humans don’t claim to be infallible.”