All Entries Tagged With: "inpatient status"

Possible MIC audit issues that involve case management

Editor’s Note: This post was excerpted an article on the Revenue Cycle Institute Web site.

There’s no question that audit activity is escalating.

It’s no longer just RAC, MAC, CERT, and ZPIC audits looking to ensure the accuracy of Medicare payments. Providers are also subject to increased scrutiny on the Medicaid side, as states are working with the federal government to help reduce payment error rates and recoup overpayments.

The scrutiny comes in the form of Medicaid Integrity Contractors (MICs), who will begin auditing providers in all states by the end of 2009.

What will MICs be auditing? It will vary from state to state, of course. But James G. Sheehan, the Medicaid Inspector General for New York, listed several issues he expects the MICs will audit during the October 15 HCPro audio conference, “Medicaid Integrity Contractor Audits: Know What to Expect and How to Prepare.”

The following are some of the potential MIC audit issues Sheehan listed that case management staff members should be aware of:

• Heart failure and shock. For this issue, MICs will look for failure to meet InterQual criteria for inpatient care.
• Ambulatory surgery with no complications to justify inpatient stay. “Commonwealth Fund just came out with a ranking of the states on this issue, and some states are better than others. It may not be a bad idea to find out where your state stands and whether this will be an issue,” Sheehan says.
• Observation beds. This is always a popular issue because Medicaid rules differ by state and also differ from Medicare in most states, explains Sheehan.

Editor’s note: Sheehan and Sarah Kay Wheeler, partner at King & Spaulding LLP in Atlanta spoke during the October 15 HCPro audio conference, “Medicaid Integrity Contractor Audits: Know What to Expect and How to Prepare.”

For additional background information view the April 22, 2009 GAO report “Improper Payments: Progress Made but Challenges Remain in Estimating and Reducing Improper Payments,” visit the GAO Web site.

Update on case management protocol

In our last post on case management protocol, we said we were trying to reach CMS for a definitive answer as to whether case management protocol is an acceptable practice.

Since then, National Government Services (NGS), one of the largest Medicare contractors in the country, has released a statement in response to several providers asking it to sign off on a specific case management protocol.

The statement, dated April 22, 2009, states that CMS does not require NGS to approve of individual providers’ specific protocols, as approval by Contractors of individual policies might imply a predetermination of payment. NGS also says that RACs do not require a signed statement of approval or allowance of case management protocol, and this has been verified by CMS.

In regard to the compliance of a case management protocol, the statement cites CMS Publication 100-2, Chapter 6, Section 20.6, which states:

“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 order outpatient tests.”

CMS Publication 100-2 Chapter 1, Section 10 states:

“An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that he or she will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight. The physician or other practitioner responsible for a patient’s care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient.”

NGS points out that a patient cannot be considered an inpatient until a physician has signed off on the admission order. Even if a standing order is written “admit to case management protocol”, patients will not receive inpatient status until the physician signs off on it. An example given by NGS is a patient admitted on a Sunday via case management protocol, but the physician doesn’t sign off on the order until Monday morning. In the example, the patient is not considered admitted as an inpatient until Monday morning.

This is something to keep in mind for facilities that have these types of written standing orders. If the patient admission is delayed until the physician signs off, it could have unplanned effects, such as the patient not qualifying for skilled nursing facility care due to the three-day qualifying stay rule.

However, there are some facilities that have made this protocol work for them. Keep an eye out for future stories in our monthly publication, Case Management Monthly.

Let us know how your facility successfully handles admissions and level of care status, whether with a case management protocol or other process.

Admitting patients to “inpatient status”

I received a question recently about admitting patients to “inpatient status.” This was specifically related to a patient who is in the Emergency Department, and a physician writes the order “admit to inpatient;” the patient remains in the ED waiting for a bed (they may be considered an ED boarder).
From what I found in the reference below–found on the CMS website–the patient is considered “admitted to inpatient” when the order is written (dated and timed). For patients in observation being admitted to inpatient, this fact can have an impact on whether he/she was on the midnight census of the admitting date – which can then count toward the 3 day acute inpatient day making him/her eligible for extended care benefits.
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