clarifying the increased cms ur standards · insurance company will pay for the stay –los usually...
TRANSCRIPT
Clarifying the Increased CMS UR Standards
Friday, May 9th, 2014
2
SpeakerSue Dill Calloway RN, EsqAD, BA, BSN, MSN, JD CPHRM
President of Patient Safety and Health Care Consulting
Board MemberEmergency Medicine Foundation
Dublin, Ohio 43017 614 [email protected]
3
1. Explain why hospitals must have a UR plan.
2. Discuss the importance of physician documentation regarding medical necessity in medical records.
3. Describe why hospitals are required to have a UR Committee.
4. Explain new and revised standards, regulations, and laws put forth by CMS, TJC and the federal government.
5. Evaluate compliance requirements and penalties.
Learning Objectives
4
Regulations first published in 1986
CoP manual updated February, 2014 and 456 pages long
Tag numbers are section numbers and go from 0001 to 1164
First regulations are published in the Federal Register then CMS publishes the Interpretive Guidelines and some have survey procedures 2
Hospitals should check the CMS Survey and Certification website once a month for changes
1www.gpoaccess.gov/fr/index.html 2www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp
The Conditions of Participation (CoPs)
5
New website at www.cms.hhs.gov/manuals/downloads/som107_Appendixtoc.pdf
CMS Hospital CoP Manual
6
www.cms.hhs.gov/manuals/downloads/som107_
Appendixtoc.pd
7
Hospitals that participate in Medicare or Medicaid must meet the COPs for all patients in the facilities
Not just those patients who are Medicare or Medicaid
Hospitals accredited by TJC, AOA, CIHQ, or DNV Healthcare have what is called deemed status
This means you can get reimbursed without going through a state agency survey
Can still get complaint or validation survey
Mandatory Compliance
How to Keep Up with Changes First, periodically check to see you have the most
current CoP manual 1
Once a month go out and check the survey and certification website 2
Once a month check the CMS transmittal page 3
CMS reserves the right to tinker with the language in a survey memo and when finalized publishes it in a transmittal
Have one person in your facility who has this responsibility
1 http://www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf
2 http://www.cms.gov/SurveyCertificationGenInfo/PMSR/list.asp#TopOfPage
3 http://www.cms.gov/Transmittals
8
CMS Survey and Certification Website
9
www.cms.gov/SurveyCertificationGenInfo/PMSR/list.asp#To
pOfPage
CMS Transmittals
10
www.cms.gov/Transmittals/01_overview.asp
Access to Hospital Complaint DataThere is a list that includes the hospital’s name and
the different tag numbers that were found to be out of compliance Many on restraints and seclusion, EMTALA, infection
control, patient rights including consent, advance directives and grievances and standing orders
Two websites by private entities also publish the CMS nursing home survey data and hospitals
The ProPublica website for LTC
The Association for Health Care Journalist (AHCJ) websites for hospitals
11
Access to Hospital Complaint Data
12
Updated Deficiency Data Reports
13
www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Hospitals.html
The CMS Hospital CoPs on Utilization Review
14
CMS CoP Utilization ReviewThe Utilization Review section (abbreviated UR)
starts at tag 652 Has not been updated in long time
TJC amended the leadership chapter (LD.04.01.01) to require a UR plan and UR committee with at least two physician members
Added 2 EPs to comply with the MIPPA or Medicare Improvements for Patient and Providers Act
The Discharge Planning session starts at tag 699 The final discharge planning standards were effective July 19.
2013 and was 39 pages
15
CMS CoP Utilization ReviewAlso called Utilization Management or UM
Although UM describes a more proactive and concurrent process that seeks to ensure appropriate and efficient use of healthcare resources which includes managing quality and the cost of services
Utilization review is by definition a process of looking backwards to determine if the healthcare diagnosis and treatment was appropriate or appropriately applied as well as a review of services provided
Quality is linked with utilization review and management and CMS has a QAPI section and worksheet
16
Utilization Review Important in healthcare for many reasons Making sure quality care is provided
In most cost effective manner
To reduce hospital admissions and length of stays
Want to make sure care is medically necessary especially in light of the RACs or recovery audit contractors and the two midnight rule
Hospital should make sure has good UR plan and UR staff So what’s in your UR plan and in your UR program??
Should update it on an annual basis17
Two Midnight Rule It is not in the CMS CoP
It is part of the billing manual
However, still important to establish medical necessity
If patient is expected to stay at least two midnight then presumption that it is appropriate to admit the patient as an inpatient as long as not gaming the system
If less then presumption it is an outpatient observation patient
18
Two Midnight Rule Important to meet the documentation requirements Decision based on complex medical factors as beneficiary medical
history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk (probability) of an adverse event occurring during the time period for which hospitalization is considered
Physician signs the order and a certification
Law passed delaying it 6 months and RACs on vacation
Order should read:
Admit an inpatient to 7 tower or
Place in an outpatient observation bed19
CMS FAQs on Two Midnight Rule
20
www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/Questions_andAnswersRelatingtoPatientStatusReviewsforPosting_31214.pdf
Many CMS Memos on 2 Midnight Rule
21
Admission Order & Certification
22
Physician Certification
23
24
25
26
Utilization Review Plan
27
Utilization Review Policy
28
Utilization Review Critical Access HospitalsCurrently Medicare reimbursement for CAHs is not
based on DRG designation so not subject to mandatory reviews No similar UR section in the CAH manual for Medicare
patients
However, Rural Healthcare Quality Network (RHQN) recommends hospitals conduct internal reviews using the InterQual criteria if possible (many private insurers use)
Recommend this even though other criteria sets are available and less costly
Notes that in the future mandatory reviews may become a reality
29
Utilization ReviewCertification (justification) may be required for
certain procedures or a hospital stay before an insurance company will pay for the stay– LOS usually assigned by physician or nurse reviewer,
hospital committee, insurance provider or a combination of the four
Medicare reviewers currently use InterQual criteria when reviewing medical records to establish if inpatient admissions were medically necessary
InterQual (or Milliman-USA) criteria are used by case managers when conducting inpatient utilization review
30
Utilization Review InterQual criteria are clinically based on best practice,
clinical data and medical literature
The criteria are updated continually and released annually
The criteria is the first level screening tool to assist in determining if the proposed services are clinically indicated and in the appropriate setting Can’t be use to deny a case as only physicians determine
clinical appropriateness
If does not meet then case is referred to a physician reviewer for further determination of medical necessity
31
Utilization ReviewHospital and the attending physician will have the
opportunity to provide additional information on the inpatient Medicare patient that may not have been available to the physician reviewer
Of course, case may still be denied and there will be opportunity to request a review by a different physician reviewer
If second physician reviewer denies it then opportunity to have case reviewed by an administrative law judge (ALJ)
If denied, Medicare takes money back for payment of the hospital stay
32
QIO Role in UR This is why it is important for hospitals to respond back
to notices in a timely manner
This is the amount of time indicated on the letters received from the Quality Improvement Organizations or QIOs
The QIO does the peer review activity for CMS
Every state has a QIO under contract by CMS
QIO is involved with the Scope of Work (SOW) which is updated every 3 years 9th SOW started August 2008 thru July 31, 2012 and 14 states worked
on care transition project (See MedQic)33
Medicare Quality Improvement Org ProgramThe Medicare QIO program was created by law in
1982 to improve quality and efficiency of services to Medicare patients
First phase in the early nineties did this through peer review (PRO) to identify cases where professional standards were not met for initiating corrective actions
In second phase, had significant changes with how to improve care and promotion of public reporting and development of scope of work projects
34
CMS and Quality of Care IOM March 2006 report recommended changes and
CMS makes improvements as result of the MMA Law Medicare Prescription Drug, Improvement, and
Modernation Act of 2003, section 109(d)(1)
CMS views QIO program as the cornerstone to improve quality and efficiency for Medicare patients
CMS undertaking activities to manage and measure quality and they want value based purchasing and has a roadmap
More under discharge planning35
CMS Roadmap for Quality Measurement
36
9th Scope of Work SOWMany times surveyor will ask to see if the hospital
has signed a contract with their QIO to participate in the SOW
Many times if this is done CMS surveyor may not scrutinize the UR standards 14 states worked on the Care Transition Project to promote
seamless transition across settings including hospital to home and to prevent readmissions
Ten focus areas; heart failure, MRSA, pressure ulcers, R&S, AHRQ culture tool, surgical care, drug safety, public reporting, LD and quality assessment tool
Focused disparities (diabetes) and chronic kidney disease37
9th Scope of Work SOWQIOs will continue to review quality of care given to
Medicare patients, beneficiary appeals of certain notices, potential EMTALA, and implementing QI activities as a result of case reviews, sanctions etc.
Some states adopted some of the initiatives
Some measures overlap with IHI (Institute for Healthcare Improvement) 5 Million Lives Campaign and 100K live campaign
Some also overlap with American Heart Association on the Get with the Guidelines campaign (GWTG)
38
Medical NecessityCMS takes the position that whether a patient
should be admitted as an inpatient is a complex medical judgment that should be made by the physician based on;
Severity of the “signs and symptoms” exhibited by the patient,
Medical probability of an adverse outcome for the patient, and
The need and availability of diagnostic studies
See MLN Matter SE103739
CMS Guidance on Hospital Inpatient Admissions
Medical necessity is a hot button with the RACs, Medicare Administrative Contractors (MACs), fiscal intermediaries (FIs) and comprehensive error rate testing (CERT) contractors
CMS released an educational guideline to assist hospitals regarding inpatient admission decisions
To help ensure that hospitals are using proper screening criteria to analyze documentation and make medical necessity determinations Chapter 6 of the Medicare Program Integrity Manual, Section 6.5 is
available at http://www.cms.gov/manuals/downloads/pim83c06.pdf on the CMS website
40
Transmittal SE1037 1/25/2011
41
Medicare Program Integrity Manual
42
www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads
/pim83c06.pdf
Medicare Benefits Policy Manual
43
www.cms.gov/manuals/Downloads/bp102c01.pdf
Inpatient Review for Medicare PatientsA tool used by the QIO may be helpful to determine
medical necessity but does not guarantee payments for admission or continued stay
Demographics Patient name, ID number
Attending Name and contact information
The day or dates under review
SI (symptom intensity) How sick is the patient? This places the patient’s services in context with their clinical condition and is needed both for the initial review and for concurrent review
44
Medical NecessitySymptom intensity (continued)
What is the main clinical issue?
Abnormal vital signs?
Pain present- where, what is the cause?
Neurological status: alert to obtunded
Brief description of diagnostic tests (especially if lab or x-rays are abnormal)
Any consultations and evaluations or procedures?
45
Intensity of Services IS (Intensity of services) What care is the patient
receiving?
IV medications and frequency
Any IV PRN meds given for nausea, pain? How often each day?
IV Fluids/ TPN
Blood or blood products (should have a HCT as a reason)
Oxygen needed? FiO2 and route? ABGs done or O2 sats?
46
Discharge Screens DS (Discharge Screens) What is the long-term plan? An “unsafe” discharge will initiate a quality of care review. What is the expected destination after
hospitalization?
What discharge planning activities are being done
What care needs are there post discharge? Educational Needs?
Are there any significant psychosocial issues?
47
Intensity of Services Intensity of Services continuedDiet/Tube feeds/gavage (what is infants weight)
If patient is on a sliding scale, What were the high/low glucose values? How many coverage units were given on each day (not the routine doses)?
Wound management: describe wound and dressing/debridement/special issues
Any other treatments or therapies?
48
Information on the QIOs
49
www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/QualityImprovementOrgs/index.html?redirect=/qualityimprovem
entorgs
50
www.qualitynet.org/
List of all QIOs
51
52
Utilization Review A-0652 Hospital must have a UR plan that provides for
review of services furnished by the institution and the members of the MS to Medicare and Medicaid beneficiaries
UR plan should state responsibility and authority of those involved in the UR process
Surveyor will make sure activities performed as in UR plan
Need to include review of medical necessity of admissions
53
Utilization ReviewReview of medical necessity for: Appropriateness of the setting
Extended stays and
Professional services rendered
This is really important in light of the Recovery Audit Contractors or RACs American Hospital Association, AHIMA, and CMS has
website of resources for the RACs
RAC program to identify improper Medicare payments including overpayment and underpayments
AHA Website on RAC Program
54
http://www.aha.org/aha/issues/RAC/index.html
CMS RAC Website
55
http://www.cms.gov/rac
56
http://ahima.org/resources/rac.aspx
Survey Procedure Tag 652These are the questions to the surveyors to verify Determine that the hospital has a utilization review plan
for those services furnished by the hospital and its medical staff to M&M patients.
Verify through review of records and reports, and interviews with the UR chairman and/or members that UR activities are being performed as described in the hospital UR plan.
Review the minutes of the UR committee to verify that they include dates, members in attendance, extended stay reviews with approval or disapproval noted in a status report of any actions taken.
57
UR PlanUR Plan should say who is on the UR committee Such as the physician advisor, CNO, discharge planners,
social services, business office manager, HIM director, administration, UR nurse, billing office, etc.
Should discuss meeting frequency such as meets once a month
It should address conflicts of interest so anyone with financial interest in the hospital can not be on the committee
Should include a confidentiality section so all data, minutes, worksheets are confidential
58
Functions of a UR CommitteeShould include functions of the UR committee such
as: To establish and carry out a program of admission
certification and continued stay review of all patients in accordance with applicable state and federal laws and regulations
To supervise the utilization review activities of non physician reviewers
To assure coordination between concurrent review activities, quality assurance, and risk management activities, and reimbursement agencies
59
Functions of the UR CommitteeTo assist in the selection and ongoing modification
of criteria and standards
To recommend changes in hospital procedures, medical Staff practices or continuing education programs as indicated on analysis of review findings
To act on any topics referred to them by the Medical Staff, Administration, or any other hospital committee
To address potential over-utilization or under utilization issues
60
UR PlanUR plan can include the method of review All patients admitted to the hospital will reviewed by the
UR nurse for appropriateness and medical necessity
Includes M&M patients, CHAMPUS, patient insurance covered by private contract, self pay, etc.
What guidelines are used such as InterQual or Milliman etc.
Concurrent reviews are done using the same criteria or the information provided by the insurers
If criteria does not exist then will work with physician and patient and family to move the patient to the appropriate level of service
61
UR Plan If UR nurse sees unusually high costs or frequent
ordering of excessive services then can talk to physician advisor
Or can subject case to Preadmission Review or in-depth peer review
Decisions made by UR nurse will be based on standards adopted by the MS and QIO
Include in the policy the preadmission review process
Precertification of elective surgeries should be done by the physician’s office but hospital will verify precert
Include admission review process62
Utilization ReviewMake sure you get observation rules correct especially
with condition code 44 and two midnight rule
CMS issue UR CoP Memo June 2, 2007
Exception for UR plan is if the Hospital has an agreement with the QIO in their state to assume binding review Hospitals may have a contract with QIO to review
admissions, quality, appropriateness and diagnostic information related to Medicare inpatients
Surveyor will look to see if hospital has a signed contract with their state QIO
63
64
Composition of UR Committee 654
Consists of 2 or more practitioners who carry out UR function
At least 2 members must be doctors
The UR committee must be either a staff committee of the hospital or
A group outside that has been established by the local medical society for hospitals in that locale and established in a manner approved by CMS
65
UR Committee 654A committee may not be conducted by an
individual who has a direct financial or ownership interest (5% or more) or
Who was professionally involved in the care of the patient whose case is being reviewed
Surveyor will look to see if the governing board has delegated UR function to a outside group if impracticable to have a staff committee
66
Frequency of Review 655
UR plan must provide review for Medicare/Medicaid (M/M) patients with respect to medical necessityAdmissions (before, at, or after admission)
– Usually should screen within one working day of admission and use severity of illness or intensity of service as discussed previously
Duration of stay
Professional services furnished including drugs and biologicals
67
Scope of Reviews A-0655Reviews may be on a sample basis except for
reviews of cases assumed to outlier cases because of extended stay cases or high costs
Surveyor will examine UR plan to determine if medical necessity is reviewed P&P should state what to do such as UR nurse speaks
with attending, goes to the physician reviewer, when ABNs are issued, IM Notices, QIO guidelines etc.
If IPPS hospital there should be a review of the duration of stay in cases assumed to be outlier
68
Admissions or Continued StayDetermination that admission or continued stay
is not medically necessary is made by one member of UR committee if the physician concurs with determination or fails to present their views when afforded the opportunity Must be made by two members in all other cases (656)
Before determination not medically necessary, UR committee must consult the MD responsible for the care and afford opportunity to present their views
Hospital Discharge Summary Form
69
70
Admissions or Continued Stay Then committee must provide written notification no
later than two days after determination to the hospital, patient and practitioner responsible for care
If attending doctor does not respond or contest the findings of the committee, the findings are final
If physician of UR committee finds not medically necessary no referral of committee is necessary and he may notify the attending doctor
If non-physician makes the determination it must go to the committee or the physician reviewer
A non-physician can not make this final determination
Review of Professional Services 658The committee must review professional services
provided
To determine medical necessity
And to promote the most efficient use of available health facilities and services
Topics for the committee may include overuse or underuse of necessary services
Timeliness of scheduling of services such as diagnostic and operating rooms
71
72
This presentation is intended solely to provide general information and does not constitute legal advice. Attendance at the presentation or later review of these printed materials
does not create an attorney-client relationship with the presenter(s). You should not take any action based upon any information in this presentation without first consulting legal
counsel familiar with your particular circumstances.
73
The End! Questions???Sue Dill Calloway RN, Esq.
CPHRM, CCMSCP
AD, BA, BSN, MSN, JD
President of Patient Safety and Education Consulting Board Member
Emergency Medicine Patient Safety Foundation
614 791-1468