Medicare audit program still going strong

Medicare audit program still going strong

Make sure requirements of IPPS are met

Don’t be fooled into thinking that the Medicare auditors will go away just because the Centers for Medicare & Medicaid Services (CMS) has declared that a stay spanning two midnights is presumed to be appropriate for an inpatient admission.

"Auditors are still going to be looking for the money in any place they may find it. Just because CMS says there is a presumption that a stay is inpatient if it’s two midnights or longer doesn’t mean the auditors aren’t going to be looking at these stays. They’re going to review two-day stays to make sure the order is correct and they meet medical necessity criteria and the other requirements of the Inpatient Prospective Payment System final rule if the hospital bills for an inpatient stay," says Linda Sallee, MS, RN, CMAC, ACM, IQCI, a director at Huron Healthcare with headquarters in Chicago.

All of the Medicare auditors are likely to look at two-day stays for trends just as they do now, adds Kathleen Miodonski, RN, BSN, CMAC, manager for The Camden Group, a national healthcare consulting firm based in Los Angeles.

"They’re already looking at hospital Program for Evaluating Payment Patterns Electronic Reports (PEPPER) and tracking medical necessity when hospitals keep patients three days and transfer them to a skilled nursing facility. That’s not going to change," she says.

Hospitals that appear to be gaming the system and keeping patients for two days to get inpatient reimbursement will be subject to more audits, Miodonski says. "This makes it even more important for case managers to use diligence in applying criteria and supporting physicians in documenting a true and complete picture of the patient," she says.

The auditors are likely to spend a lot of time looking at cases where patients stay three midnights and are transferred to a skilled nursing facility, adds Deborah Hale, CCS, CCDS, president and chief executive officer of Administrative Consultant Service, a healthcare consulting firm based in Shawnee, OK.

"There are occasions when it is determined that a patient did not meet the test of medical necessity for the entire three-day inpatient qualifying stay but they did need skilled care. Should CMS deny the inpatient stay but determine that the services provided during the three-day stay were medically necessary, the skilled nursing facility stay would not be denied as non-covered," she says.

There are situations when a one-midnight stay is appropriate for an inpatient stay, points out Ralph Wuebker, MD, MBA, chief medical officer for Executive Health Resources, a Newton Square, PA, healthcare consulting firm. These include when a patient has a procedure on the Medicare inpatient-only list, if a patient leaves against medical advice, is transferred to another hospital, or dies.

"There are going to be other exceptions, such as when patients come in very sick and the physician expects them to stay over two midnights and the patients get better quicker than expected and go home the next day. But these are rare events," Wuebker says.

In those cases, if the medical record is clearly documented so the auditor can clearly see that the physician had the expectation that the patient would stay two midnights and the stay was medically appropriate, the hospital stay should not be denied, he adds.

The emphasis on documentation makes it important to have case managers on hand to assist the physicians at least during peak hours, Miodonski says. She suggests that hospitals look at the cases in which they are losing reimbursement because of the various Medicare auditors’ denials, where the decisions are being made in those denied cases, and look at the return-on-investment the hospital may expect if it adds case management staff and denials are reduced.

"It would be great to have case managers on duty 24-7, but it may not be possible, particularly in smaller hospitals," Sallee says. Cover peak hours and put tools in place so supervisors can assist the physicians in off-peak hours, she suggests.

"In the final rule, CMS says that a case manager should be available at all times to support physicians. Clearly, this is an unfunded mandate and something most hospitals cannot afford," Hale says.

Hospitals do need to have case managers at any point of entry into the hospital, Hale says. "Every hospital is different. It depends on which door has the highest volume and is most problematic," Hale says. For instance, a surgical specialty hospital might not need case managers in the emergency department, but may need more than one in surgery scheduling.

In Hale’s experience, the first thing many hospitals should consider is adding case managers to review surgeries and procedures in the cardiac catheterization laboratory. "The inpatient versus outpatient decisions are frequently incorrect in these areas and often there is nobody there to make sure they are correct at the outset," she says.