The final rule for the Inpatient Prospective Payment System (IPPS) for fiscal 2016 continues the CMS transition from Medicare fee-for-service to reimbursement that is based on quality.
“We are seeing an increase in value-based reimbursement as opposed to reimbursement for volume. This is still evolving and it remains to be seen how Medicare reimbursement will look in the future,” says John K. Hall, MD, JD, MBA, chief clinical officer for Executive Health Resources, a Newtown Square, PA, consulting firm.
In the final rule, issued July 31, CMS announced that it was adding new metrics to Value-Based Purchasing, the Hospital Readmission Reduction program, and the Hospital-Acquired Condition Reduction program, either effective Oct. 1, when the rule goes into effect, or in the future.
“There are no surprises in the final rule. CMS is continuing a steady movement toward a reimbursement system based on quality,” says Linda Sallee, RN, MS, CMAC, ACM, IQCI, director for Huron Healthcare with headquarters in Chicago.
The final rule adds a care coordination measure to Value-Based Purchasing in fiscal 2018. The measure, which has been in the Hospital Inpatient Quality Reporting program, is a combination of metrics from three questions on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) that a focus on patients’ understanding of their care when they left the hospital. CMS also will add a 30-day mortality for chronic obstructive pulmonary disease in 2021.
The rule expands the population of patients with pneumonia in the readmissions program to include patients with a principal discharge diagnosis of pneumonia, aspiration pneumonia, and sepsis with a secondary diagnosis of pneumonia present on admission.
CMS is expanding the Hospital-Acquired Condition program to include data for central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) from all medical/surgical locations.
CMS announced that is continuing to implement the Bundled Payments for Care initiative, which links payments for multiple services during an episode of care into a bundled payment and thanked commenters for their feedback on policy and operational issues surrounding the potential expansion of bundled payments.
“Case managers have a real opportunity to help their hospitals deliver top-quality care and to improve patient outcomes. Traditionally, case managers have focused on utilization review and discharge planning but now they need to add care coordination to their focus and ensure that patients get the care they need in a timely manner and in the right setting,” Sallee says.
She suggests that case managers dig down to determine what is causing patients to come back to the hospital over and over, and work with the social workers to help ameliorate the social factors that keep patients from following their discharge plan.
“Case managers should look at the clinical care and make recommendations as necessary to help drive the progression of care,” she adds.
The discharge plan that case managers develop can have a huge impact on the hospital’s bottom line under a bundled payment initiative, Sallee points out. “With today’s length of stay, case managers need to start talking to patients early and to take the time to find out everything they need to know to create a successful discharge plan,” she says.
“Other than the doctor, the case manager is the one constant during the patient stay. They need to be someone who coordinates care and be the glue that pulls everything together,” she says.
This year’s IPPS postpones action on the two-midnight rule until CMS issues the Outpatient Prospective Payment System (OPPS) final rule in late October, Hall points out.
“The final rule didn’t change anything that could affect what case managers do. Until the OPPS is issued and we see if there are changes in the two-midnight rule, case managers should maintain a compliant review process,” he says.
In the OPPS proposed rule for 2016, issued July 1, CMS proposed allowing shorter stays to be reimbursed as inpatient stays if the documentation in the medical record supports it. The proposed changes left the policy unchanged for stays of two midnights or longer.
CMS has continued the moratorium on Recovery Auditor (RA) reviews on short inpatient stays until the end of the year, Hall says. RAs have been auditing for medical necessity but have been forbidden to audit for patient status, he adds.
In the OPPS proposed rule, CMS also proposed that the two Beneficiary and Family-Centered Care Quality Improvement Organizations (QIOs), Livanta and KEPRO, take over the responsibility of Probe and Educate and will review cases for medical necessity when patient stays are one midnight or less.
If hospitals have consistently high denial rates, the QIOs will refer them to the Recovery Auditors for patient status reviews, CMS said in the proposed rule.
“We don’t know the details yet, but it appears that short inpatient stays may be eligible for RA review at the recommendation of the quality improvement organization,” Hall says.
The final rule for the Inpatient Prospective Payment System for fiscal 2016 continues the CMS transition from Medicare fee-for-service to reimbursement that is based on quality.
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