Same-day readmission probe affects access
Hospitals pressured to defend level of care
The Health Care Financing Administration’s (HCFA) new investigation of hospitals with a higher than usual number of Medicare same-day readmissions has huge implications for access, says Jack Duffy, FHFMA, corporate director of patient financial services for Scripps-Health in San Diego.
The extreme pressure on hospitals to defend the level of care chosen for each patient will result in clinical expertise being refocused on the front lines of access, he predicts. "[Hospitals] are going to be rapidly putting case management nurses back into the front of the access department. [Access personnel] will have to ask a whole new level of clinical questions and be familiar with InterQual, or [hospitals] will make a lot of mistakes, provide the care and then not get paid, or have the money taken back." InterQual, Duffy explains, is one of a handful of systematic approaches to understanding who should be an inpatient. For many diseases, it provides a score or some verifiable clinical indication that a patient needs a particular level of care. [InterQual Products Group, Marlborough, MA, is a subsidiary of McKesson-HBOC. For more information on the system, call (800) 582-1738 or visit the Web at www.InterQual.com.]
HCFA is increasingly using sophisticated computer technology to zero in on above-average numbers of claims for various services, he says. "They’re having so much fun with computers that they’re saying, Let’s look at some more things.’ A hospital has 32% more claims than predicted for [a particular service], the documentation doesn’t support the code, so now that hospital is writing [the government] a check for $1 million."
In March, the Office of the Inspector General asked HCFA to investigate hospitals with above-average claim rates for multiple, continuous same-day readmissions. HCFA was instructed to look at a sample of claims in which same-day readmissions were coded with the same diagnosis-related group as the first hospital stay.
"With same-day readmissions," Duffy says, "the patients come in, sometimes for a procedure, sometimes not. They look OK and are sent back to the nursing home. Then after that, they crash, the ambulance brings them back, and the hospital would like to bill that as a discharge and readmission so Medicare will have to pay for both."
HCFA’s position, on the other hand, is that if there was a premature discharge and the patient shouldn’t have gone home, those two stays should be collapsed into one, he adds. "There are times when it appears to HCFA that hospitals are trying to gain additional reimbursement. But if there are two diagnoses, the hospital should be compensated for both of them.
"In hospitals where [the access department] never lost nurses, there might have been preadmission screening, he points out, "but in a lot of hospitals, when managed care came in, outpatient preadmission departments were de-emphasized. Now the clerical population is taking those physician orders and can’t question them. They’re not trained to do so."
Scrutiny of the level of care will only become more intense, Duffy says, because of the relative ease with which HCFA can farm out claim analysis to companies that specialize in that area. "[HCFA] will say, Let’s look at this three-day stay with admission to a nursing home. Maybe the physician is just using the stay to get someone into the nursing home.’"
In the case of one-day stays, he adds, "[HCFA] is saying, That patient should probably have been an outpatient. Let’s see if the hospital is meeting guidelines.’"
PROs join war on crime’?
Medicare peer review organizations (PROs) have been put on notice by HCFA that they are needed in its "war on crime," he says. "We’re seeing it in the request for charts. The PRO is saying, We’ve selected your hospital and are choosing from this menu these types of [patient] stays. We’re using the computer to prescreen and then are going to a more specific investigation.’"
Organizations that perform an oversight function for Medicare have been charged with a new task in recent months, says Kathy Warren, MS, chief operating officer for Qualidigm, a Milltown, CN-based quality improvement organization. "It’s the sixth scope of work,’ something all PROs have to do. As part of the payment error prevention program, [PROs] have to engage in activities that are going to prevent hospital billing errors — coding [mistakes] and inappropriate admissions."
Although it’s not dictated by HCFA exactly what each PRO looks at, Warren adds, "if one-day admissions are more than the norm, that certainly raises questions."
This new tack, Duffy says, "may require a rapid response from access to be able to meet the PROs on level ground." At a recent VHA West meeting, he adds, discussion focused on whether that response should be to re-establish a nursing presence in access. "At a patient accounting round table, which has a strong access orientation, this was clearly on [participants’] minds. This was a California group, and the way access developed is that preadmission departments went away. It was pretty universal. We’re facing a rebuild."
At hospitals in some areas of the country, he says, nurses may still be doing preadmission testing and assigning the level of care. For those in states like California, Duffy adds, the message is clear. "If you moved away from a strong front-end nursing presence, put it back in a hurry."
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