where we’ve een…where we are…where we might be headed...where we’ve een…where we...

Where We’ve Been…Where We Are…Where We Might Be Headed

Ronald Hirsch, MD, FACP, CHCQM-PHYADV

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV

ProHealth Care, Inc.

4/14/2019 2R1 is a registered trademark of R1 RCM Inc. All rights reserved. Proprietary Confidential Information

▪ Review readmissions

▪ Explain patient notices

▪ Talk About Clocks

▪Mention Medicare Advantage

▪ Defend physician behavior

Objectives


▪ Review readmissions

▪ Explain patient notices

▪ Talk About Clocks

▪Mention Medicare Advantage

▪ Defend physician behavior

Objectives


And Thank You to All of You!!!!

Courtesy Dr. Charles Locke, President, American College of Physician Advisors

SAR ACIR

LTACH

Inpatient Psych

JailALFInpatient Drug Treatment

Geri-Psych

Locked Dementia UnitNH

Shelter OSH TBI Rehab

Hospice

Home + IV Abx, TPN, wound care, PT/OT, TFs, Home PD, Home HD, etc…


▪Hospital Readmission Reduction Program – HRRP

▪Hospital Value-Based Purchasing – VBP

▪Hospital Consumer Assessment of Healthcare Providers and Systems – HCAHPS

▪Hospital-Acquired Condition Reduction Program –HAC

▪ Bundled Payment Programs – BPCI, CJR

What is Health Care Quality?


Why 30-Day Readmission Penalty?

From: Preventability of Early Versus Late Hospital

Readmissions in a National Cohort of General

Medicine Patients

Ann Intern Med. 2018;168(11):766-774.

doi:10.7326/M17-1724

What about SDoH and Readmissions?

Health Services Research, Volume: 54, Issue: 2, Pages: 327-336, First published: 08 March 2019, DOI: (10.1111/1475-6773.13133)

Blue- higher penalty

Yellow- lower penalty

Overall change in

penalties in millions if

readjustment applied

Factors

Area Deprivation Index

Dual Eligibility


▪ SEP-1 – Antibiotics within 3 hours for sepsis

Vs.

▪ CDI – Clostridium difficile infections

Clashing Values


Correlation Between Patient Safety and HACs

https://webalyticos.home.blog/2019/01/21/overall-star-ratings-challenges-to-credibility-new-insights/


High Patient Satisfaction is a Goal???

In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.Arch Intern Med. 2012;172(5):405-411. doi:10.1001/archinternmed.2011.1662


Bundled Payments Must Work, Right?

July 19, 2018N Engl J Med 2018; 379:260-269DOI: 10.1056/NEJMsa1801569


What About Rating Agencies?


How Not to Do Readmissions

https://twitter.com/MWFriedberg/status/1104368054979436544


▪ Medicare−Combine readmission on same calendar day for same

reason−Don’t combine if readmission on same day but for

different reason−Don’t combine if readmission on any other day

(regardless of reason)

▪ Non-Medicare−Follow the same guidelines− If insurance wants to combine or not pay

• Contracted? Rules per contract• Not contracted? If Medicare Advantage (MA) plan,

must follow CMS regulation

What’s the Rule?


▪Medicare readmission in 30 days, pays full DRG

▪ Readmission in target area goes to penalty for 3 years

−Actual readmission rate compared to expected rate

• Ensure all comorbid conditions are documented

▪ Preventing a readmission probably means less revenue (DRG>penalty)

▪ Readmission reduction programs require costly FTEs

▪ But readmission rate affects overall Star rating

What’s the Money?


▪ Develop a system to alert providers/ED staff if patient had recent admission

▪ Did patient already have 3 day inpatient stay so can go right to SNF?

▪ Can patient be “tuned up” in Obs for one midnight?

−If not, or if passes second midnight, admit as inpatient

What Should You Do?


▪ Preventing readmissions that can be prevented is the right thing to do

▪ Ask the patient “What happened?” and fix that

▪ Ensure documentation describes circumstances of readmission

−“Did not follow diet instructions”

−“Refused to let home health RN in house”

−“Home care RN did not show up”

−“Patient could not get appointment with specialist”

What Should You Do?


Document Social Determinants of Health (SDoH)


▪None are CCs or MCCs

▪ Coders measured by charts coded per hour

▪ Coders don’t review case management or social work notes for codable diagnoses

Argument Against Documenting SDoH


▪ SDoH responsible for trillions of dollars of health care

▪ If we don’t report them, who will?

▪Would you not code a medical illness that does not affect payment?

▪ CMS and others look back 3 years for data when developing penalty or reward programs−In 2022, they will look at your 2019 SDoH rate and

adjust your 2023 payments

Argument For Documenting SDoH


▪Medication reconciliation must be thoughtful−Did pharmacy change to new drug in class for

formulary? or

−Did doctor change to new drug in class for efficacy?

−Does patient know which to take when they get home?

−Is the med rec form legible and understandable by the patient?

What Can We Do?


▪ Does the patient still need to take the medication?

−Was it started as hospital preventive (e.g. PPI?)

−Was it ordered as a PRN that won’t be needed?

−Will the primary care provider know why the new med was started?

−Will the patient be able to afford the medication? Is it on their formulary?

Medications and Readmissions – Partners in Crime


Antipsychotic prescribing patterns during and after critical illness: a prospective cohort study doi: 10.1186/s13054-016-1557-1


We Have Medicalized Life – Medications for a 92 y/o

De-prescribing – schedule your patient for a

medication debridement


▪MOON – Medicare Outpatient Observation Notice

−Medicare and MA patients +/- state rules

−More than 24 hours of Observation starting with order

−May give at onset of Observation

−Shouldn’t give to non-Observation patients

−Requires verbal explanation

−If you miss one, investigate but OK to bill stay

Patient Notices


▪ IM – Important Message from Medicare

−All Medicare/MA inpatients

−Must be within 2 calendar days of admission

−Follow up copy within 2 calendar days of discharge

−Notifies patient of right to appeal discharge to BFCC-QIO

−Don’t give to every patient (seen it)

−Don’t give IM and MOON to every patient (seen it)

Patient Notices


▪ Attending has ordered discharge

▪ Check if IM given within 2 days

−If not, stop, give IM, offer 4 hours to contemplate

▪ Tell patient they are discharged

−If patient agrees, discharge patient

−If patient disagrees, offer option to talk to doctor

• If patient still disagrees, ask patient to call QIO as described on IM

Discharge Appeals - What’s the Process?


▪QIO should call you

▪QIO should instruct you to give Detailed Notice of Discharge to patient

▪Wait for determination (and wait and wait and wait)

▪ Remember

−read instructions carefully for each form

−Fill out neatly and completely

Patient Calls QIO


▪Give patient HINN 12

▪Not obligated to provide unnecessary care

▪ Liability begins

−Noon next day if QIO determination

▪ Patient can request redetermination by QIO but incurs costs during appeal

QIO Gives Determination Supporting Discharge


▪Give patient HINN 12

▪Not obligated to provide unnecessary care

▪ Liability begins midnight that day

▪ Patient can request appeal from QIO after HINN but incurs costs for day(s) prior appeal

Patient does not Appeal


▪ Patient remains inpatient during their liability

▪ Billing staff will report days from discharge order to QIO response as provider liable with Occurrence Span Code 77

▪ Billing staff will report days after QIO determination as patient liable with Occurrence Span Code 76

▪ Occurrence Code 31 for date that patient given HINN 12

▪ Value Code 31 with charges to patient

▪ If/when patient gets sick again, resume necessary day billing

Billing Patient Liable Days


▪ The HINN we love to hate

▪Medically unnecessary service provided during medically necessary stay

−Defibrillator ordered on heart failure inpatient and EF 40%

−DRG 291- HF w/CC- weight 1.3454

−DRG 226- ICD w/CC- weight 6.8182

−Provide HINN 11 and occurrence code 32 for date of HINN, value code 31 on charge, list non-covered

HINN 11


▪ Patient stable for discharge but physician won’t write order

▪ Asks QIO to make determination

▪ You’ll likely never use this so look it up if needed

▪ Better to get your physician advisor to call the doctor

HINN 10


Patient arrives in ED Monday at 11 pm, triaged at 11:10 pm, CBC ordered for abdominal pain at 11:25 pm, ED doc sees patient Tuesday at 12:20 am, Observation ordered at 2:15 am for abdominal pain, pain resolves, patient sent home at 5 pm

Let’s Talk Clocks


▪ Starts with symptom-related care in the ED or transferring hospital

Patient arrives in ED Monday at 11 PM, triaged at 11:10 PM, CBC ordered for abdominal pain at 11:25 PM. ED doc sees patient Tuesday at 12:20 AM, Observation ordered at 2:15 AM for abdominal pain, pain resolves, patient sent home at 5 PM.

Two Midnight Clock started at ___________?

The Two Midnight Clock


▪ Patient arrives in ED Monday at 11 PM, triaged at 11:10 PM, CBC ordered for abdominal pain at 11:25 PM. ED doc sees patient Tuesday at 12:20 AM, Observation ordered at 2:15 AM for abdominal pain, pain resolves, patient sent home at 5 PM

▪ This patient spent how many midnights in the hospital?

Two Midnight Clock Started at 11:25 PM!


▪ Patient arrives in ED Monday at 11 PM, triaged at 11:10 PM, CBC ordered for abdominal pain at 11:25 PM. ED doc sees patient Tuesday at 12:20 AM, Observation ordered at 2:15 AM for abdominal pain.

▪ You check with RN at 4 PM, still getting Dilaudid IV Q4 hours, not eating, not going home today

▪ This patient will spend a second midnight in the hospital. You should _______________.

This Patient Spent One Midnight!


▪ Patients passing a second midnight for medically necessary care without any delays in care should always be admitted as inpatient for Medicare FFS.

▪ You should also ensure there is documentation to support that second midnight.

−“Admit as inpatient due to continued pain and IV analgesia use.”

You Should Get an Admission Order!


▪When reviewing your observation patients, how do you know when their care began?

−If Observation ordered previous day, admit Inpatient

−If Observation ordered same day, need to determine if care started prior to midnight

• Check registration time; if previous day, check chart for start of care

▪ Don’t miss these easy inpatients!

Here’s the $5,000 Trick


▪Observation hour counting begins with the Observation order, independent of location of patient

▪Observation hour counting ends with effectuation of discharge

−Hours with active monitoring must be taken out of total (job of billing staff)

−Hours of convenience should be billed with –GZ modifier as non-medically necessary

The Observation Clock


▪Observation payment from Medicare requires 8 or more hours of Observation after carve-outs

▪Observation patients do not have to stay 8 hours

−Discharge when stable

−But if very few hours, patient either

• Got better quickly (it happens)

• Never needed Observation in first place (it also happens – ED throughput initiatives)

The Observation Clock


▪ To access their Part A Medicare Skilled Nursing Facility (SNF) benefit, patient must have had 3 consecutive inpatient days, not counting day of discharge, within prior 30 days. (See also: 3 midnights.

▪ 3-day stay can be at multiple hospitals, VA hospital, foreign hospital

The SNF Clock


▪ 1965 – Medicare created

−3 days to access SNF and 3 days to access home care

▪ 1989 – 3-day rule removed

−$964 million in 1988 to $2.8 billion in 1989

−Rule promptly replaced

▪Groups have been lobbying Congress for ~10 years

−Allow Observation days to count to 3 days

−But…Congress busy with other things

The Dreaded Three Day Rule


▪ 75 y/o female with COPD presents to ED at 10 PM after a fall. X-ray shows hip fracture

▪ ED physician calls ortho and hospitalist at 11 PM

▪Hospitalist enters admission order into EHR at 11:15 PM

▪Hospitalist comes to ED 12:30 AM, dictates H&P at 1:10 AM, enters other admission orders at 1:20 AM

▪ ED RN gives report at 2:15 AM

▪ Floor RN first documentation at 4:00 AM

▪ Patient goes to OR at 8 AM

Case Example


▪ CMS counts days based on dates on UB-04 claim

−Admission date - field 12

−Discharge date - field 6 (statement covers)

▪ You look at date of inpatient admission order

▪Where do your coders get the date of admission?

Count Your Days Properly


• Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that he or she will require hospital care that is expected to span at least two midnights. MBPM Ch 1

• A patient of an acute care hospital is considered an inpatient after issuance of a written or electronic admission order authored by a practitioner who is responsible for the care of the patient. An admission order is considered evidence of the physician’s decision to admit the beneficiary to inpatient status. CMS TDL 11447

What is the Admission Date?


▪ Ask your billing staff where they get the admission date for the claim

▪ If it is anywhere other than the order, change that!

▪Medicare is location-agnostic!

To Do When You Get Home


▪ Three-plus day stay without a three-day inpatient stay and patient transferred to SNF thinking Part A will pay

−SNF will submit claim

−Claim will trigger search of common working file for 3 day inpatient admission and not find it

−SNF claim will be denied

−SNF will be angry.

What Happens if 3 Day Requirement Not Met?


▪ “Payment for SNF stays not preceded by the required 3-day hospital stay,” is a technical denial and not subject to Limitations on Liability. As such, Medicare would consider the beneficiary to be liable when the SNF stay is denied.

▪Medicare regulations do not require SNFs to verify the medical necessity of an inpatient stay prior to admission to the SNF, nor do the regulations allow the SNF to seek payment for a denied claim from the hospital.

What Happens if 3 Day Requirement Not Met?


A beneficiary’s SNF coverage is not necessarily invalidated by a retroactive denial of the qualifying hospital stay, as long as the care provided during that hospital stay can still meet the relatively broad definition of medical necessity described above. Accordingly, the denial of the hospital stay itself would affect coverage of the related SNF stay only in those instances where it is further determined that “hospitalization for 3 days represents a substantial departure from normal medical practice.” As discussed above, for purposes of qualifying for SNF coverage, an inpatient hospital stay that is retroactively denied after SNF admission could still meet the relatively broad definition of medical necessity set forth in the manual provision cited above.

2014 IPPS Final Rule

What if The 3 Day Stay is Self-Denied?


▪ If contracted, not obligated to follow 2 MN Rule−Can keep in Observation for days on end−But, if you get paid per day, that’s not always bad

▪ If not contracted, MUST follow 2 MN Rule−If they don’t, first appeal & then call CMS if denied

▪ Ask your contracting office to get an extra per diem rate for days waiting for payor to give SNF approval

▪ Ask the patient to call the insurer, CMS, Congress

Medicare Advantage Nightmares


Medical Necessity Can Vary Within Same Payer

UHC Commercial Plans

UHC Medicare Advantage Plans


Discharge Planning CoP – 3 Days Before Expiration Date


California – Ahead of the Curve


What Inspired This?


The Untold Stories


About 30 minutes later the nurse returned to my mother's room and gave her a folder. She told my mother that her discharge instructions were in the folder along with a prescription. The nurse told mother if she started having another allergic reaction to return to the hospital. At this point, I spoke up because the agency I am employed with partners with the particular hospital for Care Transitions. I started thinking about what is a good transition. I started thinking about what if my mother was in the room alone. My mother and so many other patients will not ask questions as they want to be the "good patient" or just ready to leave. I asked the nurse about medication changes, side effects, MD follow up, etc. She was startled that I was asking so many questions and responded that the information was highlighted in the folder. My mother gave me "the look" that I was talking too much so I pretty much let it went because I planned to review all of the information in the folder and knew what was needed for my mother to have a successful transition. The last thing I will share about my mother's discharge is that the prescription was not signed. When I got to the pharmacy the pharmacist had to call back to the hospital to get authorization to fill the new prescriptions.

From a Family Member to CMS


Responding as a patient, this is a ridiculous waste of time. Need more time spent on taking care of the patient instead of creating more paperwork. Giving a patient more papers showing who has better outcomes isn't helping take care of that patient. The paper will be thrown in the garbage probably before they leave their room. There should be more people helping the patient with baths, giving medicine timely answering call lights when they are in the hospital Instead the nurse time is spent on printing out outcomes and do this and don't do that forms. Do you really think we read this garbage? It should be a one page form with who to call if having these problems

On the Other Hand


▪ Proposal added formal discharge plan for all Observations, outpatients with sedation

▪More choice, more patient involvement (shared decision making)

▪More data sent on transfer, provide quality, and resource use data on post-acute providers

▪ Final Rule by November 2, 2019 – start preparing now!

▪ Is it time for the patient’s bedside RN to do discharge planning on simple patients?

What Are They Proposing?


Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADVProHealth Care, [email protected]@DrVelvetHammer

(Courtesy of) Ronald Hirsch, MDR1 RCM Inc.Physician Advisory Solutions

RonaldHirsch.com

Questions?

mailto:[email protected]

where we’ve een…where we are…where we might be headed...where we’ve een…where we...

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