Some observation patients are demanding to be admitted as inpatients when they receive the Medicare Outpatient Observation Notice (MOON) and understand what it means, says Mindy Owen, RN, CRRN, CCM, principal owner of Phoenix Healthcare Associates in Coral Springs, FL, and senior consultant for the Center for Case Management.
“What has complicated the process and created difficulties is that some people in the media have suggested that Medicare recipients who receive the MOON request that their physicians admit them as inpatients. This flies in the face of the goal of ensuring that patients get the right care for the right reason in the right setting,” she says.
Medicare Conditions of Participation require that patients who are admitted need an inpatient level of care, Owen says. When patients don’t meet inpatient criteria and are admitted anyway, it could be construed as fraud committed by the hospital, she points out.
When patients object to receiving outpatient observation services, Owen suggests giving them the telephone number of the Quality Improvement Organization (QIO) and alerting the department that handles complaints, usually patient advocacy or risk management, that a patient is unhappy. Case managers also should refer patients to the department if they want to complain further.
“Risk management or patient advocacy won’t change the level of care, but they will allow the patient or family member to vent,” she says. “Their staff has experience in handling difficult situations, and sometimes just talking to someone will make the patient or family member feel better and drop the complaint.”
At UCHC/John Dempsey Hospital in Farmington, CT, there are few challenges to observation status, and most of them come from patients covered by traditional Medicare who are concerned about the three-day inpatient stay required for Medicare to pay for a skilled nursing facility stay, reports Mary Laucks, RN, CCM, senior director of specialty services at the hospital.
If patients covered by traditional Medicare or Medicare Advantage object to their status as an outpatient receiving observation services, the case manager asks the attending physician and a representative of the utilization review committee to review the case. If they agree that the patient should be receiving observation services, the case manager informs the patient of the decision and encourages them to appeal to the QIO.
“In some cases, the QIO has overturned the patient status but if our physicians and the QIO physician agree, the patient stays in observation,” Laucks says.
Commercial insurers present more of a challenge, Laucks says.
“We suggest that patients with commercial insurance who challenge their status to contact their insurer’s customer relations department, but in many cases, the issue doesn’t arise until after discharge,” she says.
If your hospital doesn’t have a formal process in place for delivering the MOON, complying with the CMS mandate could be a challenge.
Implementation of the MOON has to be coordinated with other departments in the hospital, including admitting, registration, and the ED, Owen says.
“It cannot be implemented in a vacuum with just case managers or utilization managers involved. It was and is a regulation that needs a collaborative approach to implementation,” she adds.
She recommends educating everyone that will be involved with the MOON on the intention and what is needed to make the implementation process work. This includes registration, admission, the ED, physicians, case management, and utilization management, she says.
Patients could receive the MOON in the ED or from registration when they come into the hospital. “Everyone needs to understand what this means to the patient and how it should be scripted,” Owen says.
Delivery of the MOON requires face-to-face interaction, Owen says. “The person delivering the MOON does not have to be a licensed health professional, but he or she does have to be delivering it under the auspices of the organization,” she says.
In some hospitals, the MOON is presented by someone in registration or admitting, Owen says. Then if the patient or family member has specific questions, a licensed professional is brought in.
Ambulatory surgery patients with a planned observation stay can receive the MOON in advance, Owen says.
“The majority of patients who receive the MOON after business hours and on weekends are likely to come in through the emergency department,” she adds.
A good time to give the MOON to surgical patients is when they come in for lab work and already are signing off on paperwork, Owen suggests.
Hospital staff have no excuse for not having a plan in place for delivering the MOON to patients, Owen says.
CMS originally mandated that hospitals be ready to implement the MOON by Oct. 1, 2016, then postponed implementation to Jan. 1, 2017, and again until March 8. “Whether hospitals agree with the requirement or not, they had sufficient time to put together a plan,” Owen says.
Some observation patients are demanding to be admitted as inpatients when they receive the Medicare Outpatient Observation Notice and understand what it means.
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