Threading the Needle: Understanding the Compliant Discharge Approach

First up, a totally unsubstantiated rumor. A Texas hospital has heard that one of their regional Medicare Advantage (MA) plans is going to start requiring a three-day inpatient stay to approve payment for a Skilled Nursing Facility (SNF) stay.

As you may know, MA plans can waive this requirement, and most do, but I have never heard of a plan withdrawing this benefit. I also do not know if the plan must notify the Centers for Medicare & Medicaid Services (CMS) and patients of the change to their benefit package, since some enrollees may have chosen an MA plan because they did not want to be stuck with the traditional Medicare requirement.

Moving on, last month we talked about discharge appeal rights for patients without Medicare Part A. This week it’s a different patient population facing the same issue. I am sure everyone knows that patients who are not admitted as inpatients do not have formal discharge appeal rights. But one hospital asked me why, when a few of their observation patients called the Quality Improvement Organization (QIO) to appeal their discharge, the QIO contacted them and asked for copies of the medical record to review.

Now, my first question for them was how in the world did the patient know to call the QIO? The QIO’s number is not on the Medicare Outpatient Observation Notice (MOON), so was it possible that the patient received the Important Message from Medicare (IMM)? Was someone in their hospital taking a shortcut and simply getting signatures on every possible form, giving an IMM and a MOON to every Medicare and MA patient who registered in the ED? Of course, we know that is not only inappropriate but also not allowed. Medicare does not allow you to deliver a form to a patient when it is not appropriate for their situation.

But putting that aside, what did happen here? Well, although the QIO cannot evaluate the patient as a formal discharge appeal, they also handle quality-of-care complaints, so they are obligated to assess the patient’s contention and whether they are being discharged prematurely – and asking for records would be part of that determination.

What can you do if this happens to you? Well, as always, the first thing to do is to try to address the patient’s concerns. Is the discharge premature? Has your physician advisor looked at the case and determined that discharge is appropriate?

If there are no issues, then your next step should be to explain to the patient that they absolutely have the right to call the QIO, but you have evaluated the situation and feel that discharge is appropriate. Then inform the patient that if they would like to stay, they are welcome to do that, but it’s not free, and they must immediately start paying your hourly rate for custodial care. Explain that filing a quality-of-care complaint with the QIO brings with it no financial protections, as there are with inpatient discharge appeals.

Since custodial care is statutorily non-covered, you do not even have to present an Advance Beneficiary Notice, but you would be smart to do that to get proof that the patient understood their obligation. You can then get a credit card number or have them Venmo you the first day or two of payment, since you know the QIO is not going to respond immediately. You should reassure them that if the QIO finds that there is an issue and determines that ongoing hospital care is indicated, you will refund any money they will have paid, but they will also be responsible for their inpatient financial obligation since you will be obtaining an inpatient admission order from the attending physician.

And of course, be sure that the patient’s physician is aware of what’s happening, and then sit and wait for the QIO to call back. I will also remind you that if your physicians have determined that the patient does not require hospital care and the patient is staying, be sure there are no IV fluids ordered, no as-needed IV medications, and no testing ordered. The QIO may see those and think “Well, if the doctor is still ordering hospital care, that seems to suggest that ongoing hospital care is necessary.”

You, of course, are also free to turn off the cable feed to the room and limit their meal selection to a basic menu. But do not do those things without going up the chain of command; the patient being fed bologna sandwiches wrapped in cellophane with a container of apple juice may feel that a call to the local media or a post on social media is warranted, and your ability to respond publicly will not exist.

Now, can you evict the patient, forcibly make them leave, if they won’t cooperate? Medicare rules do not specifically prohibit that, but I’ll leave that discussion to the lawyers, as should you.