After much anticipation, they've finally arrived. With the recent CMS approval of issues for DCS, the RAC for Region A, all four of the RACs are now actively reviewing claims for medical necessity validation. Now what?
HealthLeaders Media sat down with Michael Taylor, MD,vice president of clinical operations at Executive Health Resources in Newtown Square, PA. Taylor has extensive inpatient and outpatient experience in urban, rural, community and academic settings. Taylor has years of experience and expertise in guiding and assisting hospitals throughout all levels of the Medicare appeals process, including vast experience at the administrative law judge level.
Whether you are a provider that was prepared for the inevitable onset of medical necessity or you are now scrambling to catch up, there are undoubtedly some questions and concerns surrounding the medical necessity. Taylor spent a few minutes discussing strategies with us.
Q: What should the unprepared provider do?
A: For the provider that perhaps hasn't done its due diligence in preparation for medical necessity audits, the first course of action should be building your RAC team, Taylor says. This team should include representatives from different departments including case management / utilization review, health information management, patient financial services, legal and compliance.
Taylor suggests that, as the team members begin to build their response process, some of the questions they should be asking themselves at this point include:
Who in our organization "owns" RAC response? Since many departments will be involved in the process, who is ultimately accountable for project managing the process?
What is expected of each department involved in RAC response?
How will we gauge our level of success overall and at each step in our process?
How will we utilize the RAC response process to better identify trends and changes that could help prevent future denials?
Q: What should the prepared provider do in addition to what they've already done?
A: While there may be some facilities that aren't currently up to speed in their processes, most providers have at least done some form of groundwork. These providers likely have a team and system in place; and if they do, the next best step is to test it out by running a few drills, Taylor says.
"Submit a few mock RAC medical record request letters to test the effectiveness of your team and process," he says. "Then identify any potential weaknesses in the process and correct them before the actual letters begin arriving."
Q: What are some potential pitfalls for providers with medical necessity?
A: First, a comprehensive utilization review process is a prerequisite to a successful appeals process.
"Providers who cannot demonstrate a compliant utilization review process consisting of first level screening criteria followed by a strong concurrent second-level physician review for all inpatients who failed to meet the first-level screening criteria may face difficulties during the appeals process."
Next, and in tandem with a strong utilization review process, you must recognize that documentation is a critically important factor in building strong appeal cases for RAC medical necessity denials. Providers need to be sure that they are submitting all evidence and medical facts that support the case by the second level of appeal, he says.
Lastly, providers should not be discouraged if they do not find success in the first two levels of appeal.
"Some facilities may stop before the ALJ Level because they are intimidated by the hearing; are hesitant to pay legal fees; or begin to doubt the strength of their case," he says. "But many hospitals experience their greatest success at the administrative law judge (ALJ) level of appeal."
Q: What's the most important thing for providers to keep in mind when it comes to RACs and medical necessity?
A: When it comes to developing your appeals strategy for medical necessity, your argument should address the following components:
Clinical. Form a strong medical necessity argument using evidence-based literature.
Compliance. Demonstrate a compliant process for certifying medical necessity.
Regulatory. Show, when applicable, that the RAC has not acted in accordance with rules, regulations or other relevant CMS or contractor guidance.
In a sign that may be viewed as the first step toward Medicaid Recovery Audit Contractors implementation, the Centers for Medicare & Medicaid Services released September 10 an information collection form and supporting documents for contractors for Medicaid plans. The release of formalized information comes as no surprise, according to Elizabeth Lamkin, MHA, president of Dalzell Consulting Group, Inc., in Hilton Head, SC.
"As we learned from the Medicare RAC demonstration project, the RACs collected $1.3 billion at a cost of 20 cents on the dollar," she says. "There is a huge incentive to expand the RAC program to Medicaid."
The documents within draft form CMS-10343 would be used by state Medicaid plans to attest that they've contracted with a contingency fee auditor. The forms list several criteria for the RAC expansion, including provisions related to payment of the Medicaid RACs, appeal of adverse Medicaid RAC determinations, and coordination of Medicaid RAC activity with other reviewers and entities (e.g., the Medicaid integrity program).
According to the CMS release in the Federal Register, the forms are intended for the preparation of the RAC expansion into Medicaid, as required by the Patient Protection and Affordable Care Act:
Under section 1902(a)(42)(B)(i) of the Social Security Act, States are required to establish programs to contract with one or more Medicaid RACs for the purpose of identifying underpayments and recouping overpayments under the State plan and any waiver of the State plan with respect to all services for which payment is made to any entity under such plan or waiver. Further, the statute requires States to establish programs to contract with Medicaid RACs in a manner consistent with State law, and generally in the same manner as the Secretary contracts with Medicare RACs.
State programs contracted with Medicaid RACs are not required to be fully operational until after December 31, 2010. States may submit, to CMS, a State Plan Amendment (SPA) attesting that they will establish a Medicaid RAC program. States have broad discretion regarding the Medicaid RAC program design and the number of entities with which they elect to contract.
Because the administration of Medicaid is up to individual states, the expansion of RACs into Medicaid may in fact prove difficult, according to Lamkin.
"We do not know how the RAC contractors will interpret state rules or work with providers," she says. "We may see problems much as we did in the Medicare demonstration project based on a learning curve for providers and RAC auditors."
Providers should begin to prepare for Medicaid RACs by first educating themselves on state Medicaid rules and begin to conduct audits on high-volume Medicaid procedures to determine if bills meet criteria. In the Medicare RAC demonstration project, coding and medically unnecessary services or settings were the cause of the majority of overpayments, which providers need to learn from, according to Lamkin.
"Make this part of your RAC committee work and treat it like the Medicare RAC preparation," she says. "Get it right on the front end with documentation and systems to prevent errors, and appeal, appeal, appeal!
View the form and supporting documents by clicking here.
Diversified Collection Services (DCS) of Livermore, CA began its affiliation with the Recovery Audit Contractors program when the Centers for Medicare & Medicaid Services awarded it a three-year contract for the Medicare secondary payer (MSP) RAC demonstration contract of California in 2005.
When it came time for the implementation of the permanent program, DCS became the RAC for Region A. Since then —and much like its fellow regional RACs—it has caused providers a plethora of aches and pains since the initial round of record requests were sent.
Despite the setbacks and inconveniences that the RAC process can create, providers can lessen the potential impact and even hope to avoid denials and recoupment by implementing a comprehensive RAC process. Here are a number of tips and concepts to consider when it comes to dealing with DCS:
Focus on MS-DRGs. The specific list is growing monthly. Keep an eye on your facility's one-day stays vs. observation vs. outpatient in a bed, which may become targets in the near future, according to Stacey Levitt, RN, MSN, CPC, director, patient care management at Lenox Hill Hospital in New York City. "Also focus on short stays of less than 24 hours, but billed as inpatient, specifically for low trim point DRGs," she added.
Review your charts. Review internal records and charts for lack of coding specificity; sequencing errors (ICD-9); incorrect combinations of codes; failure to assign multiple codes when available; nonspecific signs and symptoms; and use of complication codes, according to Levitt. "Query the physician if documentation is insufficient or nonexistent," she says. "Remember, if it's not documented; it didn't happen!"
Identify problem areas. Work on any potential weaknesses with your RAC and HIM teams and be proactive, says Levitt. "Review DRG, diagnoses and procedures against DCS targets," she says. "In addition, establish effective communication between the coding staff, CDI program staff, and the medical staff."
Know your RAC contact information. The DCS project director, Catherine Till, can be reached at (925) 960-4712. The CMS project officers for DCS are Ilene Jacob and Scott Wakefield. They can be reached at (410) 786-7444 and (410) 786-4301, respectively.
Identify MAC target areas. "Stay ahead of the RACs by understanding the Medicare Administrative Contractors (MACs)," says Michael Taylor, MD, senior medical director, Government Appeals and Regulatory Affairs for Executive Health Resources (EHR) in Newtown Square, PA. By recognizing issues that the MACs are focusing on, it will help to identify potential RAC targets.
Prepare for the administrative law judge (ALJ) level. All appeals should be detailed and designed to prepare for the ALJ, according to Taylor. "Your argument must address three key components to have a high likelihood of success: clinical, compliance, and regulatory."
Understand medical necessity. According to Taylor, the decision to admit is a complex medical decision which can only be made after the physician has considered a number of factors, which include: medical history; current medical needs; available facilities; hospital bylaws and policies; severity of signs and symptoms; predictability of adverse happening and findings of diagnostic studies that could assist in decision-making. More information can be found in the.
Let's face it—dealing with Recovery Audit Contractors RACs is an albatross around the neck of susceptible providers. But for diligent hospitals that have anticipated RACs since the demonstration project, the situation is far less dire.
A recent update to the evaluation of the RAC demonstration shows that HealthDataInsights (HDI), the RAC for Region D, had the highest percentage of claims overturned on appeal, which shows that, like providers, HDI is not perfect.
With this in mind, consider the following tips to help develop a conscientious approach from start to finish, which can augment providers' chances of success throughout the RAC process.
Know your number limit when it comes to medical record requests. Based on the current formula, limits are based on the servicing provider's tax identification number and the first three positions of their ZIP code; and set at 1% of all claims submitted for the previous calendar year, divided into eight periods (45 days), according to Jennifer McManis, RHIT, the compliance/privacy officer at Bozeman Deaconess Hospital in Bozeman, MT.
Develop an audit tool. When it comes to medical records and their related claims, this is a must, according to McManis. "The tool should focus on appropriate DRG assignment, appropriate assignment of complications/comorbidities, appropriate principal procedure assignment; and the coding source," she says. "In addition, it should address discharge disposition validation and medical necessity validation."
Determine what you are going to review. The timeline is short for appealing unfavorable findings, so reviewing all the records before the request may not be possible, says McManis. "Review the data that is already out there," she says. "Identify where your facility may be an outlier for areas that are considered at risk, such as chest pain, stroke, one-day stays, and so on."
Use the discussion period. This period of time was implemented by CMS as a way for providers to have an open discussion about how a RAC may have made a determination, and allows the provider to offer additional information, according to Debbie Mackaman RHIA, CHCO, regulatory specialist for HCPro, Inc. "This is a valuable resource for providers looking to avoid the appeals process," she says.
Know how and when to appeal RAC determinations. A facility's RAC team should determine which charts contain documentation to support the appeal, according to Mackaman. "This requires expertise from all areas of your team," she says. "In addition, request the credentials of the HDI review staff, and request to talk to the contractor medical director, when appropriate."
Develop a letter template. Use the letter—which should contain the complete information needed—at every level of appeal for consistency, and provide explicit detail to support your position, according to Mackaman. "Be sure to include the judgment of the admitting physician and a letter supporting medical necessity," she says. "This will also help with keeping inside the timelines, which need to be monitored. If a deadline is missed, your appeal is finished!"
Develop a tracking tool. This tool, which should track all aspects of the RAC process from additional documentation requests to the resolution, needs to cover the who, what, where, when of a decision, according to Mackaman. "Pay attention to the details here, and don't just count on your memory!" she says. "There is no such thing as being over-preparedness when it comes to the RAC process."
With the release of the 2011 IPPS final rule on July 30 comes a number of changes that providers will need to have a handle on in regard to the three-day payment window.
The three-day rule states that all diagnostic services provided three calendar days before the calendar day on which the patient is admitted, are bundled and paid as part of the inpatient stay. Non-diagnostic services on the day of and for three days before an admission will now also be considered part of the admission.
Operationally, hospitals have had problems following the three-day payment window rule for years. Hospitals that are scrambling to adapt while trying understand the ramifications of the rule should consider the following list of tips and pitfalls to avoid:
Immediately determine what processes your facility follows in regard to the three-day payment window. How is your facility processing claims, and was it different, or did it deviate from what CMS has in the Claims Processing Manual, Chapter 3, §40.3 manual? If your facility did not strictly follow the Claims Processing Manual, you should look at some test claims. The test should be to see how a claim would have been reimbursed if performed according to the manual and how was it actually reimbursed. Your facility will need to look at both versions to see if in fact they would have had DRG assignments that would have been up-coded or down-coded, or otherwise changed, according to William L. Malm, ND, RN, healthcare consultant for Craneware.
Do not drastically change your methodology. Don't go back and try to change something you've already done because you can't reopen a claim, according to Malm. In addition, do not take the approach of waiting to see what the final CMS guidelines will be and continue using the regulation from before June 25th. "If something is completely unrelated, then you should continue to bill as unrelated," he says.
Avoid deeming services unrelated unless a "reasonably prudent" person could come to the same conclusion, Malm continued. "For example, you have an ambulatory surgery visit on Monday for a cataract repair. On Wednesday, you are admitted for a motor vehicle accident with multiple traumas. The 'form and function' here are clearly unrelated, and a 'reasonably prudent person' would be able to make this determination."
Lean on CMS guidance. If you are receiving advice that is not consistent with Medicare Claims Processing Manual and Benefits Policy Manual regulations, you more than likely are having an issue. "Consulting the rule and law itself is the prudent course of action for providers," says Malm.
Keep in mind that nothing has changed for diagnostic services provided before an inpatient admission, according to Kimberly Anderwood Hoy, JD, CPC, director of Medicare and Compliance for HCPro, Inc. "However, non-diagnostic services on the day of admission and for three days before an admission will now be considered part of the admission," she says. "For services in the three days before admission, but not the same day, hospitals can demonstrate they are unrelated and continue to bill separately to Part B."
Understand that the new rule may require a look at the clinical situation of the patient, according to Hoy. "Depending on the final discussion of the standard of 'unrelated,' outpatient services may need to be reviewed by a person with a clinical background prior to being billed separately, rather than being done by a coder or compared by the billing system of matching diagnoses."
Adjust billing practice for services provided since June 25, 2010. This should be done to ensure non-diagnostic services on the day of the admission are not billed separately, according to Hoy. "In addition, hospitals should develop a process to review services in the three days before for clinical-relatedness and documentation of services that are unrelated to support separate billing."
Voice your opinion. "As always, I encourage everyone to comment (by September 28, 2010) to CMS with any questions and concerns they have," says Hoy. The address and instructions are at the beginning of the 2011 final rule.
Inpatient rehabilitation facilities (IRF) were the recent target of two OIG reviews. While the reports on the reviews contain information pertinent to IRFs, the official Centers for Medicare & Medicaid Services (CMS) response to the findings is notable to many different types of providers.
The first report, a nationwide review of IRF transmission of patient assessment instruments for calendar years (CY) 2006 and 2007, showed that IRFs didn't always submit required patient assessment data in timely fashion, which would trigger a reduction in the case-mix group payment, according to Nancy J. Beckley, MS, MBA, CHC, president of Nancy Beckley & Associates LLC in Milwaukee, WI.
Included in the audit were 10,338 claims (worth $166 million in payments) that were at high risk for overpayment because the assessment data was transmitted to the National Assessment Collection Database after the allowed 27-day deadline. Based upon these findings, CMS concluded that fiscal intermediaries (FI) made overpayments of $20.2 million to IRFs in CY 2006 and 2007.
In addition, FIs may have made an additional $19 million in overpayments due to lack of clarity in the regulations regarding data for claims originally submitted within the 27-day time frame, but later resubmitted to correct errors outside of the 27-days allowed, according to CMS.
The second report reviewed IRF compliance with Medicare's transfer regulation during fiscal years (FY) 2004–2007. If a patient is discharged to home, Medicare pays the full prospective payment to an IRF. However, Medicare pays a lesser amount for a transferred patient, according to Beckley. In this particular case, the issue was whether the proper status codes were used on IRF claims.
Based upon the sampling of 220 claims, the review determined that 213 claims were improperly coded as discharges resulting in overpayment of $1.2 million. CMS concluded that FIs were overpaid $34 million for the four-year period ending September 30, 2007.
Of particular note to providers in this report is the CMS response. CMS administrator and Chief Executive Officer Marilyn Tavenner indicated that CMS will share the OIG audit information with the RACs and "encourage them to consider these findings as they decide what claims to review," according to Beckley.
Another item of which IRFs should take notice is the sampling period used by the OIG in the transfer regulation review from FY 2004---2007, according to Tanja Twist, MBA/HCM, director of patient financial services at Methodist Hospital of Southern CA in Arcadia. "In her May 13 response to the OIG's draft report, Tavenner specifically states that CMS concurs with the look back period identified by the OIG," she says. "Providers should take note that not only does CMS intend to recover the $1.2 million in overpayments, but they also plan to implement the OIG's recommendation to review and potentially recover the entire population of claims in the sample period."
CMS implemented an edit in the common working file to identify transfer cases for IRF in April 2007. Prior to that, the OIG estimates that based on their total sample size of 5,703 claims reviewed between 2004 and 2007, there were between $34 and $37 million in overpayments paid to providers, according to Twist.
CMS seems to clearly separate the sampling period as being outside the scope of the RACs, so providers may be asked to pull IRF records dating back to FY 2004 for review and potential recoupment by the FI and Medicare administrative contractors (MACs), according to Twist.
"CMS stated they will share the data with the RACs for possible review of post-audit period claims moving forward to ensure their edits are working properly," she says. "But if this sampling period is not managed by the RACs, will CMS recoup identified overpayments prior to completing the appeals process?"
In addition, providers should consider the fact that there appears to be no record pull limitations or recoupment guidelines as is mandated for the RACs in the permanent program. Providers should keep these factors in mind going forward, according to Twist.
"IRF facilities need to consider these matters when planning for their post-payment appeal processes," she says. "In preparation, they should also ensure that they are compliant with the transfer regulations outlined by CMS to avoid future issues."
CGI Technologies is the first Recovery Audit Contractor to post issues approved by CMS. All but one of them comes as no surprise, says one regulatory affairs expert.
Finally, the wait is over. The first set of approved medical necessity issues were posted August 12th by CGI Technologies and Solutions, the Region B Recovery Audit Contractor (RAC), following an AHA announcement last week that the initial review audits had been approved by the Centers for Medicare & Medicaid Services (CMS).
Medical necessity issues have been a hot topic for months. In a May CMS Open Door Forum call, a CMS representative suggested that medical necessity issues had been submitted to CMS, but CMS had not yet approved them —yet anticipated doing so in the "near future." However, the delay comes as no surprise, according to Michael Taylor, MD, senior medical director of government and regulatory affairs at Executive Health Resources in Newtown Square, PA.
"This is very consistent with the pattern we've seen with RACs since the roll out of the permanent program," he says. "CMS has been very deliberate in vetting the subjects that RACs are allowed to review."
Eighteen issues for medical necessity review were posted to the CGI website, and all but one of them comes as no surprise, according to Taylor.
Syncope and collapse MS-DRG 312 (Medical necessity review and MS-DRG validation)
Red blood cell disorders with MCC MS-DRG 811 (Medical necessity review and MS-DRG validation)
Other vascular procedures w CC, w/o CC/MCC MS-DRG 253, 254 (Medical necessity review and MS-DRG validation)
Other circulatory system diagnoses with MCC MS-DRG 314, 315, 316 (Medical necessity review and MS-DRG validation)
Chest pain MS-DRG 313 (Medical necessity review and MS-DRG validation)
Atherosclerosis with MCC MS-DRG 302 (Medical necessity review and MS-DRG validation)
Heart failure and shock with MCC, with CC and w/o CC/MCC DRG 127 MS-DRG 291, 292, 293 (Medical necessity review and MS-DRG validation)
Esophagitis, gastroenteritis and miscellaneous digestive disorders w/MCC DRG 182 MS-DRG 391 (Medical necessity review and MS-DRG validation)
Musculoskeletal disorders 539-541, 545-558, 564-566 (Medical necessity excluded except for MS-DRG 551 and 552)
Nervous system disorders MS-DRG 052-063, 067-074, 077-086, 088-093, 097-099, 101, 102 (Medical necessity excluded except for MS-DRG 056, 057 and 069)
Cardiac arrhythmia and conduction disorders with MCC or w/CC DRG 138, MS-DRG 308, 309 (Medical necessity excluded except for MS-DRG 308)
"In looking at percutaneous cardiovascular procedures, it says that medical necessity is excluded except for DRG 249. This came as a bit of a surprise because during the last year, the MACs have been heavily auditing DRG 247, which is a drug eluting stent, instead of 249, which is non-drug eluting, and a less common target of contractor attention," says Taylor. "It will be interesting to see if the RACs and MACs maintain this slightly different focus; if their areas of review are being purposefully kept apart; or if this is just a temporary situation before the rest of these stents become an approved medical necessity issue for the RACs."
Nine of the 18 issues posted were also revisions of existing DRG validation issues, which were subsequently selected to add medical necessity review. These are areas where there is a dual vulnerability, where not only are the issues oftentimes considered to be medically unnecessary by the auditor, but also hospitals sometimes miscategorize the DRG as well, according to Taylor.
"There is a concern that some hospitals might be avoiding certain high-risk DRGs by tending to assign other DRGs which don't accurately describe the service, but escape audit," he says. "This will provide the RACs with the ability to make sure hospitals aren't misclassifying these DRGS into something that is a related but inappropriate DRG, in addition to making sure the cases are medically necessary."
There is no doubt that most hospitals have been preparing for the arrival of medical necessity issues for quite some time. For those that have been preparing appropriately, this arrives as an expected development, and will be "life as usual" according to Taylor. But for those who haven't prepared, this serves as the final warning that they've only got weeks until they receive their first potential denials, he says.
"While hospitals should have been preparing for this, I will make the point that it's not necessarily too late for those that haven't," he says. "Be sure you know who is going to be receiving the requests at your organization, and make sure that you can respond to these requests. One of the worst mistakes you can make is to be unprepared for the additional documentation requests that are soon to be coming."
And for those providers outside of Region B that are relieved to see your hospital is not yet susceptible to medical necessity review; don't breath your sigh of relief just yet.
"Expect medical necessity issues from the other RACs very soon," says Taylor. "This will be nationwide in no time."
The long wait for medical necessity Recovery Audit Contractor (RAC) reviews will soon be over. The Centers for Medicare & Medicaid Services (CMS) has approved the first "medical necessity review" audits for the recovery audit contractor (RAC) program, according to a statement by the American Hospital Association(AHA).
"This should certainly not come as a surprise to providers," said Debbie Mackaman RHIA, CHCO, regulatory specialist for HCPro, Inc. "We've been waiting for these reviews since the implementation of the permanent program, often wondering what might be taking so long."
CMS takes the position that the decision to admit a patient is a "complex medical judgment" made by the patient's physician after consideration of the severity of the signs and symptoms; medical probability of an adverse outcome for the patient; and the need and availability of diagnostic studies.
A RAC will have to find clear evidence in the medical record using CMS and clinical guidance to make the opposing determination that the physician's judgment was correct, according to Mackaman.
"This will be an interesting twist to the current set of approved issues, which are more 'cut and dry'," said Mackaman.
The newly approved audits include 18 types of inpatient hospital claims and one durable medical equipment claim. It is unclear as to which RACs will post which issues to their websites, as required by CMS. According to the AHA, these issues, as well as the accompanying additional documentation requests (ADR), are expected to be released within the next two weeks.
When providers receive these ADRs, they should take the time to carefully review all documentation well in advance of receiving the review results letter, suggests Mackaman.
"The review should involve clinical staff and CDI specialists, as well as a physician advisor in preparation for a denial and possible appeal," she says. "Knowing where you stand and being prepared to take on the denial will save critical time as these issues continue to unfold."
It is hoped that hospitals have been heeding the advice to prepare for the medical necessity phase of the permanent RAC program, but if they haven't, they certainly can't put it off any longer, said Tanja Twist, MBA, HCM, director of patient financial services at Methodist Hospital of Southern California in Arcadia, CA.
Among the critical items facilities must be prepare for, Twist said, are:
Additional RAC record pull requests
Setting up side-by-side review teams to evaluate the stability of the records being requested
Whether or not to appeal cases where a determination has been received
Reconvening RAC team meetings
Fine-tuning the tracking system
Monitoring the RAC website every day for activity.
"The industry simply can't afford to bury its head in the sand any longer," says Twist. "The RACs are coming."
Recent approval of a Region C Recovery Audit Contractor (RAC) issue for inpatient hospital claims review has initiated uncertainty among providers, putting an emphasized onus on them to lean on Centers for Medicare & Medicaid Services (CMS) guidance and policy manuals.
The issue, "inpatient admissions without a physician's inpatient admit order," may be referenced in the Medicare Claims Processing Manual, Section 50.3 which states that "patients are admitted to the hospital as inpatients only on the recommendation of a physician or licensed practitioner permitted by the State to admit patients to a hospital." While the posting of this issue may have come as a bit of surprise, it has long been one of the basic premises of accurate billing, according to Deborah Hale, CCS, CCDS, president and CEO of Administrative Consulting Service, LLC in Shawnee, OK.
"There's so much written in the Medicare Benefit Policy Manual stating that the decision to admit as inpatient is a complex medical judgment that can only be made after a physician has taken into consideration a number of clinical and safety factors," she said. "It [the manual] stresses the importance of the physician making a conscious decision to admit as inpatient, and that is the foundation for everything in this process."
One factor that may confound facilities is that many have dubbed it the first official medical necessity issue approved by CMS. While technically it may not be, and though some may argue the point, this new Connolly RAC issue is, in fact, consistent with establishing medical necessity for services provided, according to Hale.
"While this is technically not a medical necessity issue as most hospitals define medical necessity (i.e., the case may meet necessity for inpatient admission), if they don't have an order, they don't have a billable inpatient admission," she said.
In addition to the medical necessity argument, a number of MACs have been providing information that is contrary and inconsistent to CMS guidance, according to Hale. One example of this is telling providers that the admit order can be rolled back if the patient was in observation first.
Yet Hale points out that this is not in compliance with CMS. In fact, a CMS representative addressed the issue of rolling back an admit order during an Open Door Forum last fall, stating that: "The hospital cannot "roll back" the time or date of admission. If the inpatient stay began with the physician's order at 8:00 a.m. on Tuesday and the patient was admitted directly from observation, the observation charges are included on the inpatient bill. Since the observation is included on the inpatient bill and paid as part of the DRG, there is no separate payment for observation."
Providers receiving inaccurate or contrary information should contact their MAC in writing, and cite the appropriate references from CMS, the Benefit Policy Manual, or the Claims Processing Manual, and ask why their instruction is contradictory to CMS. "This will at least call for some accountability," said Hale.
"The number one thing I would say to providers is to be sure that you've got a properly worded order for admission, and number two, be sure that you're not rolling the date of admission back" she said.
"Also, be sure to have an internal process set up for looking at [the] presence of a properly worded admission order and documented medical necessity of admission from the beginning of the stay, not just based on screening criteria, but also physician advisor review, if screening criteria are not met," Hale said.
Some doctors have been reluctant to communicate with patients via e–mail, in part because of reimbursement and medical liability concerns. But a new study in Health Affairs provides a compelling case for opening up the inbox to patients: It may improve the quality of care.
Researchers at Kaiser Permanente followed 35,423 patients with diabetes, hypertension, or both, over a two–month period. Those that used e–mail to communicate with their doctors saw a statistically significant improvement in measures from the Healthcare Effectiveness Data and Information Set, a group of performance measures used by the managed care industry.
E–mailing physicians helped improve “control measures” for chronic conditions in particular, says Yvonne Zhou, PhD, director of analytics, evaluation, and knowledge management with Kaiser Permanente. Glycemic control, cholesterol levels, and blood pressure screening measures were 2–6.5 percentage points higher for patients who had e–mail access to a physician.
“Many chronic condition patients really need to have ongoing communication with physicians, especially for control measures like glycemic control and LDL control,” she says. Frequent communication makes it easier to closely monitor and adjust medication levels and quickly react to changes in health, she explains. “These are the big improvement areas for using e–mail.”
The study was a follow–up to previous research Zhou conducted, which found that e–mail communication could reduce the need for office visits by up to 10% and reduce the telephone calls to a practice by 14%.
Despite the administrative and quality benefits of e–mail communication with patients, not all physicians are ready to adopt it in today’s fee–for–service environment. Some argue that e–mail consultations should be reimbursed because they are like a virtual office visit. Others are concerned that delays in responses or information provided in e–mails could increase liability risks.
But potential payment reforms could change the incentives for e–mail use, says Zhou. If Medicare can transition to a performance–based payment system, instead of one based on procedures, then physicians will be able to focus more on patient outcomes instead of individual procedures and visits. “From that perspective, it will probably encourage more doctors to use e–mail, because ... [e–mailing] improves the performance of quality measures,” Zhou adds.
Kaiser had a capitation arrangement with the physicians who participated in the study, so they weren’t operating under the same financial incentives as many doctors.
Even without an overhaul of the reimbursement system, physician–patient e–mail will likely become more common and necessary. Nearly 40% of physicians communicated with patients online in 2009, according to a survey, up from just 25% in 2006. Zhou and her colleagues noted that secure physician–patient e–mail was one of the objectives of the HITECH Act, which provides incentives for electronic health record adoption. And e–mail may be a key tool for reducing readmissions, which has been a goal of recent reform efforts.
“Follow–up e–mails after patients get discharged are really important,” Zhou says. “They can help patients cope with some of the conditions when they get home, which may also reduce readmission rates.”