Revisiting Designating Patient Discharge as AMA

At times, it can seem as though the chips are stacked against hospitals. There are a multitude of organizations collecting hospital claim data and monetizing it.

Federal, state, and private organizations are publicly reporting on hospital quality of care. Insurers are modifying their payment policies, often to the detriment of hospital financial stability. And hospitals are often held responsible for the actions of others, as with readmission measures.

While preventing readmissions is a noble endeavor, most readmissions occur because of factors totally out of a hospital’s control, including food deserts, high copayments for medications, prior authorization programs that hinder patients from receiving necessary care, and lack of solutions for the social drivers of health.

But hospitals have at their disposal a vastly underutilized tool to reduce the adverse financial effects of readmissions via the Centers for Medicare & Medicaid Services (CMS) Hospital Readmission Reduction Program and the multitude of payer policies that hold hospitals financially liable for nearly all readmissions. And that tool is designating more patients as departing against medical advice (AMA).

Hospitals should consider liberalizing the use of designating patients as discharging AMA when the patient does not agree to a recommended treatment plan, such as insisting on going home to an unsafe environment, or when the insurer will not approve the post-acute care destination that the medical team feels is necessary. If that patient does get readmitted, and the odds are certainly higher, then the readmission will not be included in the CMS penalty program – and many payors will pay the readmission in full, rather than withholding payment, as specified in their policy.

As the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) noted in a review of patients leaving against medical advice, there are no formal guidelines on the use of the AMA designation, and it is the responsibility of the provider to determine when it is appropriate. I have discussed this in depth in an earlier article.

And that recommendation is getting traction. Last week, I received an email from the vice president of care management for a large West Coast healthcare system who told me her organization has started to widen their use of AMA. She wrote that “this initiative has received strong backing from our legal, risk, and medical/legal ethics teams, as well as overwhelming support from our physicians. Many physicians expressed frustration at feeling compelled to order discharges they believed were unsafe, worrying that doing so implied their agreement with those decisions.”

Now, how often do you get every department and the physicians agreeing to anything? If you have not considered it, please read my blog and decide if it is right for your hospital.

But then she also asked me a question that I am still contemplating. She asked about the patient who agrees to the recommended discharge plan, discharges, but then does not follow through – and whether that discharge can be coded “against medical advice.” For example, say you discharge home with home care services, but the patient refuses to allow the nurse in the home. Or say the patient is discharged to a skilled nursing facility (SNF), but then gets there, is disappointed, and calls their family to pick them up and take them home.

Can the claim for these patients’ hospital care be amended to discharge against medical advice, since the patient ultimately did not follow the team’s medical advice, increasing their risk of readmission and other adverse outcomes in an environment deemed unsafe?

We must consider that if that patient was discharged with home care and turned away the nurse at the first visit, the claim would be amended to show that their discharge destination was simply home, so as to not invoke potential transfer DRG adjustment, so why not instead change it to AMA? As you could guess, I have tried without success to get an answer from CMS, so it’s up to each facility to decide what to do.

The number of hospitals closing around the country continues to climb, with many more struggling to keep their doors open. To further that financial quagmire by allowing penalties to be imposed for activities over which hospitals have no control makes no sense.

Broader use of the AMA discharge code is not the cure-all for every hospital, but every dollar counts.