QIO Decisions on Appeals Raises Questions

I really did hope to avoid having to criticize a Medicare contractor again, but then I got an email from a hospital.

But first, I reported that the Centers for Medicare & Medicaid Services (CMS) had cancelled most of their Open Door Forums (ODFs) two weeks ago. The fact that one was left on the schedule gave a glimmer of hope. But we all know how that goes.

Last Thursday, CMS canceled that call. All ODFs are now canceled, with no resumption in sight. Dr. Oz’s Senate hearing to be appointed to head CMS was last week, so we should soon have an official Administrator. Perhaps we will then start getting some sense on what to expect in day-to-day operations and communication.

But on to my critique: first, it certainly seems that many more patients are appealing their discharges than ever. When I asked at a recent meeting if case managers were in fact seeing more, there was clear agreement. But it is not clear why. I stopped reading AARP News when they told patients to demand to be admitted as inpatients, but would not be surprised if they told members to always appeal your discharge. That perhaps may be one reason. Is this a big topic of conversation at senior centers, when they are playing cards or doing chair yoga? Not out of the realm of possibilities.

I do think there is also an issue with access to high-quality post-acute providers, be it skilled nursing facilities (SNFs) or home care agencies. When patients see that the only available providers have low Star Ratings, perhaps they choose to appeal, hoping their choice will improve in a few days. And of course, we have all made our hospitals way too comfortable, with room service, high-speed internet, and all private rooms. Heck, if there were private rooms in all hospitals in the 90s, the sponge bath scene on Seinfeld with George could never have taken place.

But I digress. My criticism is that in the last week, I heard about two Quality Improvement Organization (QIO) determinations on discharge appeals that made no sense. The first was a patient whose treatment was complete, and they had no post-acute needs, but they had unstable housing. The patient appealed and won. What? Hospitals now have to find permanent housing for patients? In this case, the hospital did contact the QIO, and were told that the determination was incorrect – and that they had some new physicians reviewing discharge appeals, and they would do some additional education with all their staff.

I also heard about an appeal of a Condition Code 44 change under the new process that also was hard to understand. This was an elderly patient who lived alone and came to the ED with back pain. They had fallen a few days ago, and were having difficulty with ambulation. X-rays revealed a subacute lumbar spine fracture. Neurosurgery was consulted, and no intervention was necessary. Their pain was controlled with Tylenol. The patient was admitted as an inpatient, but was switched back to outpatient with observation, as the patient was stable, ambulating (albeit slowly), and pain was controlled. The surgeon did order a brace and kept the patient awaiting its delivery three days later. As a result, the Medicare Change of Status Notice was issued.

The patient appealed, and the QIO ruled in their favor. It is just not clear why the QIO determined that inpatient admission was warranted.

Now, I am hoping that these cases are outliers. If they want hospitals to keep patients until stable housing is found, they are going to have to increase DRG rates significantly. And if they want us to count convenience delays in two-midnight counting, I doubt anyone would object – as long as the admissions are exempt from later audit and recoupment.

What we really want is one set of rules, applied consistently. These improper decisions help no one.

Programming note:

Listen live every Monday morning when Dr. Ronald Hirsch does his Monday Rounds on Monitor Mondays with Chuck Buck, 10 Eastern and sponsored by R1-Physician Advisory Services.