The Art and Science of Status Assignment

Providers need to fight for their patients in ways the insurance companies don’t.

Medicine is both an art and a science, not a game. Screening criteria, scoring systems, and guidelines like InterQual and MCG help determine medical necessity and patient status: inpatient or outpatient.

Culled from huge data sources, they represent a scientific way to apply medicine to populations, not individuals. They allow prompt recognition of specific diagnoses and suggest effective interventions: concepts like the golden six hours of management for open fractures or limb ischemia, or prompt initiation of antibiotics and fluids in the septic patient. Prompt intervention may head off unwanted outcomes. Unfortunately, they are not guarantees of success. They are not the ultimate source of information.

Applying these scientific criteria without oversight can be risky. Classic appendicitis presents 10 percent of the time. It takes the seasoned professional to lay hands on the individual and determine their true status. The Centers for Medicare & Medicaid Services (CMS) recognizes this art as superior to the scientific guidelines. So, the dilemma exists of how physician advisors and physicians can use specific patient experiences to argue against detailed guidelines based on populations. We thought it would direct conversations on medical necessity, not be used to manipulate status determination, a clearly recognized administrative term.

As physician advisors, we are faced with using the written notes to argue for status and care. Clinical notes communicate the patient’s symptoms, signs, assessment, and proposed treatment. The healthcare team should update the notes and plans depending on the patient’s response.

Regretfully, this communication may not result in the optimization of the patient’s length of stay. Longer notes using cutting and pasting don’t guarantee inpatient status or better charge capture. Hospitals should encourage directed chart notes to avoid redundancy.

Specialists should identify key factors that are significant to their fields, plans, risks, and outcomes. Providers should be concerned with delivery of care, not administrative assignment. CMS is now focusing on medical decision-making or time, not just categories that encourage note bloat.

As physician advisors, we are perfectly positioned to guide, not lead, them to effective and efficient documentation, to ensure that their patients receive the right care at the right time in the right setting. We can remind them to tailor their notes to identify key factors for the diagnoses they are highlighting. Save them time! Target the systems at risk! How many notes on encephalopathy even try to use the prompt neuro exam of our training: recall immediately, at one minute and at five minutes for yellow, sneaker, and river unprompted, or from a list. Or respiratory distress with pneumonia: work of breathing, cough, speaking, accessory muscles, wheezing, respiratory rate, hypoxia, egophany (my favorite, even as a surgeon). Should we write “decreasing in severity” rather than “improved?” Our physicians’ notes have to be internally consistent and not give the insurer ammunition to support their denials. Specialists may identify their area of concern as resolved, but should indicate that the patient’s entire issue may be more complex.

In contrast to mutual fund giant Vanguard, whose members are their shareholders, insurers answer to their shareholders and stockholders, not their patients. Insurers reduce patients into objective numbers, avoiding any emotional connection and allowing them to limit treatment. So, treat them as such. UnitedHealthcare (UHC) has tried to control their costs with sepsis by requiring patients to meet Sequential Organ Failure Assessment (SOFA) criteria.

No wonder states like New York try to fashion laws to prevent abuse, but find them watered down by interested parties, leaving them outdated before they are signed into law. The medical community resisted, but even in Ohio, we found Medicaid using SOFA. “Surviving Sepsis 2021” tried to clarify sepsis, but is disregarded by insurers, as it doesn’t support their desire to restrict care. Insurers modify certain factors in the scoring system to minimize them when certain disease factors may alter the baseline.

Why is CMS trying to redefine prior regulations to avoid Medicare Advantage (MA) plans’ misapplication? CMS has no problem inferring fraud and extrapolating damages against hospitals and providers without a lookback time restriction if fraud is suspected. Why are they hesitating to use the same approach with MA plans? I don’t think that the government expected a profit bonanza from Medicare management when they created the commercial opportunity.

Surprisingly, when insurers are faced with a patient meeting a guideline like MCG and a length of stay over two midnights, they frequently deny based on poorly defined proprietary policies, delayed application of presentation criteria, intensity, or biased interpretations of CMS regulations. It is enough to make me dizzy. I’m still trying to understand how a patient who required BiPAP, admission to the ICU, and discharge on a new oxygen requirement did not meet inpatient status. Why do we let insurers define the rules?

Insurers admit that they don’t determine medical care. As noted, insurers reduce patients, their policyholders, to numbers, avoiding emotional connections, limiting treatment, and restricting care. Insurers modify certain values to minimize the scores when certain disease factors seem “inconvenient.” UHC even bought InterQual. Seems a clear conflict of interest? At least directed physician documentation will offer a good chance for overturn on further appeal. We should advocate for the patient, encourage them to lodge grievances, even with CMS, and not stop appealing until all opportunities are exhausted. Clearly, a success rate of 40 percent at the administrative law judge (ALJ) level indicates the value of pursuing justice for our patients beyond the insurer.

Medicine remains not only a science, but an art. Art requires a deft touch to appropriately apply the science for the specific individual. We need to base our care on the patient in front of us. They are not a “diabetic” or a systemic inflammatory response syndrome (SIRS) patient; we need to resist bundling them into a neat package so their care can be minimized. They mean much more than that.

Don’t sell patients short. Stop treating it as a game. Truth be told, we’d be playing the insurers’ game from behind, as they change the rules as soon as we respond to the old rules.