Medicare Inpatient Admissions RAC Response and Appeals Tactics - - PowerPoint PPT Presentation
Justifying Medicare Inpatient Admissions RAC Response and Appeals Tactics Gregory Palega, MD JD MedManagement LLC Medical Director of Regulatory Affairs gpalega@medmanagementllc.com Objectives Learn the Correct Medicare Level of Care
Gregory Palega, MD JD MedManagement LLC Medical Director of Regulatory Affairs gpalega@medmanagementllc.com
Defined as 24hours
Source: Medicare Benefit Policy Manual, Chapter 1
Physicians should use a 24-hour period as a benchmark, i.e., they should order admission for patients who are expected to need hospital care for 24 hours or more, and treat other patients on an
Ch 1, Section 10, MBPMs
Subjectively and Does not say
“inpatient” level be reasonable. defined on later slides
Can they reliably treat this
this town?
Source: Medicare Benefit Policy Manual, Chapter 1
decision to admit include such things as:
The severity of the signs and symptoms exhibited by the
patient;
The medical predictability of something adverse
happening to the patient;
The need for diagnostic studies that appropriately are
require the patient to remain at the hospital for 24 hours
should be admitted; and
The availability of diagnostic procedures at the time
when and at the location where the patient presents.” Can the threat be eliminated in less than 24 hours?
Source: Medicare Benefit Policy Manual, Chapter 1
required only if the beneficiary's medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting.
did not use “level of care” implies hospital location needed
the medical record, any pre-existing medical problems or extenuating circumstances that make admission of the beneficiary medically necessary.
term Care Hospital (LTCH) Claims, A. Determining Medical Necessity and Appropriateness of Admission
Without accompanying medical conditions, factors that would
money needed to care for the beneficiary at home or for travel to a physician's office, or that may cause the beneficiary to worry, do not justify a continued hospital stay. The fact that the patient or family was “uncomfortable” doing this at home means outpatient care was offered and thought reasonable and necessary by the offering MD. Identify your “wants” versus “needs”
term Care Hospital (LTCH) Claims, A. Determining Medical Necessity and Appropriateness of Admission
stick.
minimums…etc… previously defined as a 24 or more hour physical hospital setting
term Care Hospital (LTCH) Claims
Chapter 1, section 10 of the Medicare Benefit Policy Manual.
activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet, preparation of special diets, and supervision of medication that usually can be self- administered.
not require the continuing attention of trained medical
care, the intermediary or carrier considers the level of care and medical supervision required and furnished. It does not base the decision on diagnosis, type of condition, degree of functional limitation, or rehabilitation potential.
Chapter 16
appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the
patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge. Observation services are covered only when provided by the order of a physician or another individual authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to
Implementation Date: 07-06-09)
exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours. In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours.
appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the
patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge. Observation services are covered only when provided by the order of a physician or another individual authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to
don’t use these words in inpatient rationales
Implementation Date: 07-06-09)
exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours. In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours.
and is very persuasive in other jurisdictions
The determination of an inpatient or outpatient status for any given patient is specifically reserved to the admitting physician. The decision must be based on the physician's expectation of the care that the patient will require. The general rule is that the physician should order an inpatient admission for patients who are
expected to need hospital care for 24 hours or longer and
treat other patients on an outpatient basis. An inpatient admission is not covered when the care can be provided in a less intensive setting without significantly and indirectly threatening the patient's safety or health. Although in many institutions there is no difference between the actual medical services provided in inpatient and
serves to assign patients to an appropriate billing category.
Inpatient vs. Observation determination Evidentiary Rules
evidence which was available to the physician at the time an admission decision had to be made. They do not take into account other information (e.g., test results) which became available only after admission, except in cases where considering the post-admission information would support a finding that an admission was medically necessary.
Medicare Benefit Policy Manual,Chapter 1 ,Page 8, § 10 * Sacred Heart v. First Coast, Medicare Appeals Council, Nov. 10, 2009
Medicare Appeals Counsel- binding 4th level appeal
the treating physician’s medical opinion in determining the medical necessity of inpatient hospital or SNF services under section 1862(a)(1)of the Act.
context of the evidence in the complete administrative record
presumption that a treating physician’s judgment establishes Medicare coverage We have to deal with both facts and stated MD opinions /plans when determining if an inpatient LOC is supported by the record.
sections of the PIM unless otherwise indicated.
comprehensive error rate testing (CERT) contractors, recovery audit contractors (RACs), program safeguard contractor (PSCs) and zone program integrity contractors (ZPICs) shall follow the PIM as required by their applicable Statement
Medicare Program Integrity Manual Chapter 1 - Medicare Improper Payments: Measuring, Correcting, and Preventing Overpayments and Underpayments 1.1- Overview of Program Integrity and Provider Compliance (Rev. 313; Issued: 11-20-09; Effective/Implementation Date: 12-21-09)
Appropriateness of Admission
Chapter 6 - Intermediary MR Guidelines for Specific Services 6.5.2 - Medical Review of Acute Inpatient Prospective Payment System (IPPS) Hospital or Long-term Care Hospital (LTCH) Claims
RA SOW Section E 2. The Claims Review Process.
patient: Insert a brief summary of presenting signs, symptoms, and test results. Cite/add the actual key quotes from the HPI or key lab data supporting your determination.
Circumstances: List only significant history that impacts the patients risk and complexity (Generally not every surgery, fibromyalia, nor G3P1…)
to the patient: State the risk (high or low) and the applicable threat. If you recommend admission based on risk, use “high risk” here. Explain why the risk is high despite some unimpressive “numbers.” Then, describe why
health outcome was moderate to high risk for CHF/pulmonary edema and deadly high potassium (K) arrhythmias from renal failure because of his likely cardiac disease and severely elevated K. Plus, the serum creatinine does not reflect the severity of the renal failure until the renal function is in equilibrium; which takes several days after a renal insult. Meanwhile, the creatinine would only rise a point or so per day, even if both kidneys completely failed before the patient arrived.***