When Medicare Guidance is Contradictory, Where Do You Turn?

When Medicare Guidance is Contradictory, Where Do You Turn?

Let me start with another complaint about a Medicare contractor. A question recently came up on a user group about whether to provide the Important Message from Medicare (IMM) to patients with Medicare Part B, but not Part A. As is often the case, it can be difficult to find an answer in the Medicare manuals to questions like this – a simple “yes” or “no” answer.

Now, if you look at the Centers for Medicare & Medicaid Services (CMS) Beneficiary Notice webpage, it states that “hospitals are required to deliver the Important Message from Medicare to all Medicare beneficiaries (Original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospital inpatients.” Well, that sounds pretty definitive, indicating that all Medicare beneficiaries get one, and it would be hard to say that a patient with Part B but not Part A is not a Medicare beneficiary.

But then if you read the Medicare Claims Processing Manual, Chapter 30, it states that “the expedited determination process is available to beneficiaries in Original Medicare who are being discharged from a Medicare-covered inpatient hospital stay. This includes but is not limited to, beneficiaries for whom Medicare is either the primary or secondary payer. It does not include patients who have exhausted their benefits.” A patient without Part A who is admitted as an inpatient is not in a Medicare-covered inpatient stay. Now, it seems that patients with Part B but not Part A should not receive the IMM and do not have the right to an expedited appeal of their discharge. And a Medicare manual takes precedence over a statement on a webpage.

But one response to the post really caught my attention. Eileen Sullivan from Atlantic Healthcare related a case in which a patient did appeal their discharge to the Quality Improvement Organization (QIO) and lost. But they persisted, appealing to the Administrative Law Judge (ALJ). There, the ALJ noted that this patient had no Medicare Part A, and therefore, no formal appeal rights. Why in the heck did the QIO and Qualified Independent Contractor (QIC) not know this? They accepted the appeal without performing due diligence, and apparently, without knowing the rules.

Now, it should be noted that the QIOs also handle quality-of-care complaints, so the patient without Part A could call the QIO and file a complaint, and the QIO would investigate it, but that would not bring with it the patient financial protections that occur with a formal discharge appeal – and the patient may wind up none too happy to get an even larger bill if they stayed in the hospital awaiting the QIO’s decision.

As with my case outlined last week, providers should be able to count on the Medicare contractors to know the rules and interpret them correctly. Granted, our healthcare system is complicated (who knew?), but they are paid well to be the experts – and I bet that unlike us, they could pick up the phone and actually talk to a person at CMS.

Moving on, last week the New York Times had an article titled “Hospital v. Insurer Dispute May Limit Choice of Doctors.” We have seen this repeated over and over, as insurers have tried to limit expenditures on services, and providers have tried to get paid what they consider equitable compensation for the services they provide. In this case, it is United Healthcare (UHC) and Mount Sinai Health System in New York.

But what is interesting is that Mount Sinai was able to use data from public access to New York Presbyterian’s prices and contractual rates to realize that UHC was paying Mount Sinai significantly less than New York Presbyterian – and Mount Sinai wants to be paid equitably. It is interesting that the intent of price transparency may be primarily to allow patients to shop, but in this case the data may actually lead to higher charges and higher out-of-pocket costs for patients – and if Mount Sinai and UHC don’t come up with a compromise, it may also lead to decreased access for patients.

Finally, I am going to venture into Dr. Erica Remer’s Talk Ten Tuesday territory and note that the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) updated their work plan to add audits of sepsis. And if you read their introductory comments, it seems to suggest that the OIG agrees with me and Dr. Remer that sepsis requires the presence of organ dysfunction, as specified in SEP-3 – and using systemic inflammatory response syndrome (SIRS) to define sepsis is done for “financial reasons.”

Why do I think that? Well, on a basic level, septic patients are really sick, whereas many patients with fever and tachycardia may have sepsis, but some are simply expressing a normal response to an infection. They absolutely all need prompt evaluation and treatment, but looking for a condition and even starting treatment just in case they have it (but not finding it) does not qualify as a diagnosis of that condition.

Lots of patients present with chest pain, but without markers for myocardial infarction, and end up getting stents. We don’t diagnose and get paid for treating a myocardial infarction because we did the right thing and prevented it. We don’t get to code a heart transplant when we properly treat a patient with severe heart failure and prevent the need for a transplant.

Sepsis is no different, and many hope the OIG will get CMS to clean up the mess they created.

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Ronald Hirsch, MD, FACP, ACPA-C, 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, and the National Association of Healthcare Revenue Integrity, 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).

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