The Crux of Criteria: Adhering to Standards of Care

The Crux of Criteria: Adhering to Standards of Care

Have you heard enough from us yet about the new Centers for Medicare & Medicaid Services (CMS) rule requiring Medicare Advantage (MA) plans to follow the Two-Midnight Rule? You have? Well, too bad, because I have more to say. Actually, the rule has more to say, and I want to be sure you are aware of some of the other provisions.

First, it bears repeating that the use of commercial criteria by MA plans is not prohibited. The plans are more than welcome to use MCG or InterQual or internally developed criteria to approve an inpatient admission. Heck, they can use their Magic 8 Ball to approve admissions. But when it comes to denying admission or other care, then using criteria as the final arbiter is not allowed, and cases require the human touch.

As I have said before, I like criteria. Yes, I know every patient is different, and no criteria set can encompass every possible patient-disease interaction, but common things happen commonly, and criteria can do an excellent job here. The other thing that criteria do is consolidate the medical literature. The standard of care should be what is optimally done for a condition, not what is done in one facility. Dr Bill Rifkin of MCG has written extensively about that variation, and it is surprising how prevalent it is.

As an example, I recently saw data from a hospital where 100 percent of their Medicare total knee arthroplasties are inpatient. That obviously stood out. It turns out that their physician’s standard practice is to keep patients at least three days. That’s the way the doctor has always done it. They like it, and their patients like the reassurance of being in the hospital, under the doctor’s and nurse’s watchful eyes.

Now, technically, under the Two-Midnight Rule, that means this physician can admit patients as inpatients based on a more than two-midnight expectation, but is that appropriate? As a review of the literature or a glance at MCG criteria, references would tell you, the standard of care is a same-day or next-day discharge for the vast majority of patients. In a case like this, a payor can rightfully use criteria to determine that this doctor may not be practicing per the prevailing standard of care. They cannot deny inpatient admission for these patients based on criteria, but the payor and the hospital know which cases need secondary review. Perhaps a review will show that this doctor’s patients are all over 90 years old, with multiple comorbid conditions, and three days of inpatient care is appropriate. Until the record is reviewed, however, one cannot know.

The same can be applied to patients with medical illnesses such as heart failure or pneumonia. It needs to be established which patients require hospital care and for how long, and which patients need that second midnight in the hospital. Not all do. And it’s not what the doctors at St. Elsewhere do with their heart failure patients that is the determining factor; it’s really about what the standard of care is.

There is a significant amount of subjectivity here, and if objective markers such as hypoxemia or mental status abnormalities are not present, the physician’s rationale must be documented to allow a reviewer to determine if it is reasonable.

It is also important to ensure that the criteria are used correctly. Some criteria sets use the terms “inpatient” and “observation,” but not necessarily in the same way that CMS does. On the second day of admission, a patient who passes observation criteria or fails discharge screening needs ongoing hospital care, and under the Two-Midnight Rule, that means they warrant inpatient admission, not extending observation past the second midnight.

Now, what if the criteria are not met? Well, CMS makes it clear in CMS-4201-F that such tools alone cannot be used by MA plans to deny care. If care is going to be denied, it must be reviewed by a physician or other healthcare professional. But more importantly, CMS will require that the person have “expertise in the field of medicine or healthcare that is appropriate for the service at issue.”

A pediatrician is welcome to approve an adult patient’s inpatient admission, but cannot deny that inpatient admission unless they have cared for hospitalized adults. An internist who has never cared for patients in an inpatient rehabilitation facility (IRF) cannot deny an IRF admission. In fact, CMS calls out IRF admissions in their discussion, noting that qualified professionals would include “a physical medicine and rehabilitation doctor, a neurosurgeon, a physical therapist or a rehabilitation nurse” – with internist and hospitalist notably absent from that list.

It is also worth noting, as can be seen in this example, that CMS considers registered nurses to be qualified healthcare professionals for such determinations – but once again, they must have the requisite expertise.
So, starting in January, if you get a denial, feel free to ask for the person’s qualifications – and if they refuse, well, then it’s time to cause some trouble.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

Related Stories

Knowing the Score: MIPS

Knowing the Score: MIPS

EDITOR’S NOTE: Medicare’s legacy quality reporting programs were consolidated and streamlined into the Merit-Based Incentive Payment System, known as “MIPS.”  The Merit-Based Incentive Payment System

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
Mastering Medicare Notices: Your Essential Guide to the MOON and Beyond

Mastering Medicare Notices: Your Essential Guide to the MOON and Beyond

Hospital staff continue to grapple with the complexities of Medicare notices.  In this webcast, Tiffany Ferguson, LMSW, CMAC, ACM, will present the latest requirements for preparation and delivery of CMS-mandated forms, including the Advance Beneficiary Notice (ABN), Hospital-Issued Notices of Noncoverage (HINNs), Important Message from Medicare (IMM) and Medicare Outpatient Observation Notice (MOON), and practical solutions through foolproof workflows and compliance auditing.

January 25, 2024
OBGYN ICD-10-CM/PCS Coding: Mastering Complex Guidelines and Compliance

OBGYN ICD-10-CM/PCS Coding: Mastering Complex Guidelines and Compliance

Dive into the complexities of Obstetrics and Gynecology coding, addressing challenges from antepartum to postpartum care. Learn to decode intricate guidelines, tackle claim denials, and safeguard your practice’s financial health. Uncover the secrets to compliant coding, reducing errors, and optimizing reimbursement. With practical exercises and expert insights, this webcast empowers coders, auditors, and healthcare professionals to elevate their OBGYN coding prowess.

February 28, 2024
Unlocking Clinical Documentation Excellence: Empowering CDISs & Coders

Unlocking Clinical Documentation Excellence: How to Engage the Provider

Uncover effective techniques to foster provider understanding of CDI, empower CDISs and coders to customize their queries for enhanced effectiveness, and learn to engage adult learners, leveraging their experiences for superior learning outcomes. Elevate your CDI expertise, leading to fewer coding errors, reduced claim denials, and minimized audit issues.

December 14, 2023
Coding for Spinal Procedures: A 2-Part Webcast Series

Coding for Spinal Procedures: A 2-Part Webcast Series

This exclusive ICD10monitor webcast series will help you acquire the critical knowledge you need to completely and accurately assign ICD-10-PCS and CPT® codes for spinal fusion and other common spinal procedures.

October 26, 2023

Trending News

It’s Heart Month! Use code HEART24 at checkout to receive 20% off your cardiology products. Click here to view our suite of Cardiology products!