The Good, The Bad, The Ugly: Life and Times at Audit Nation

It’s another day with a few stories to report.

First up, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently fined an inpatient rehabilitation facility (IRF) in Louisiana $1.2 million for inappropriate admissions to their facility. But that is not what was unusual with this case. What stood out to me is that not only was the facility fined, but the rehab physician who reviewed and approved the admissions and provided ongoing care was also fined $575,000.

Now, granted, I have not read every single OIG report, but this is the first time I recall seeing a physician charged with making improper admission decisions. The report does note that the physician reportedly put improper pressure on patients to be admitted, so a penalty seems justified. It should also be noted that this was a whistleblower case, with two staff members of the facility earning a 20-percent reward. This case makes me wonder how the OIG would view a physician who admits inpatients to the hospital knowing that the two-midnight rule was not met, but was encouraged to liberally use inpatient status or to count delays in care as necessary days. Will a utilization review (UR) nurse be the next whistleblower getting a very nice payout?

Moving on, I have talked recently about ED visit downgrades done by payers when their proprietary tools come up with a different visit level than the facility or doctor billed. One such tool is the UnitedHealthcare (UHC) Emergency Department Claim (EDC) analyzer, and we know that UHC sells access to this tool to both payers and hospitals to use. Last week I heard a totally unsubstantiated rumor that the version of the tool they sell to payors is different than that which is sold to hospitals. If your hospital uses this tool to designate your ED facility fees, watch your claims closely. If payers are using the same tool, but still downgrading your visits, then something very nefarious may be going on.

Some of you know that Leapfrog Group released their hospital safety grades a couple of weeks ago. If you did well, I am sure your people are screaming it from the rooftops. But let me tell you about one hospital in Chicago. Roseland Community Hospital was the only hospital in the city to receive a grade of F. But here is the catch. Roseland Community received a B rating from the Lown Institute, which does not just look at a few select measures, but also at each hospital’s social responsibility, community benefit, equity, and inclusivity. Looking at the whole picture can sometimes provide a better measure of a hospital’s true quality of care.

Speaking of community benefit, last week I was in Monument Health Rapid City Hospital in South Dakota. During my talk, we discussed the Centers for Medicare & Medicaid Services (CMS) proposal to make the codes for homelessness a complication or comorbidity (CC) in 2024. Here is the thing, though: it’s easy to report the social determinants, but much harder to address them.

But Monument Health has a social worker, Hailey Twietmeyer, who is all-in on both. She goes out into her community, finds the resources patients may need, and establishes partnerships. You can tell from her passion that she loves what she does.

Every hospital needs a Hailey.

Programming note: Listen to Dr. Ronald Hirsch every Monday as he makes his rounds during Monitor Monday and sponsored by R1-RCM.