All Entries Tagged With: "RAC"

Understanding semi-automated RAC reviews

Editor’s note: The following post originally appeared on the Revenue Cycle Institute website.

Providers familiar with automated claims reviews and complex claims reviews by recovery audit contractors (RAC) now face another method of overpayment identification—the semi-automated claims review.

Semi-automated review is essentially a hybrid of the automated and complex methods of overpayment identification recognized in the RAC statement of work. CMS divides this new review process into two parts.

The first involves automated review of claims data to identify billing aberrations with a high index of suspicion of improper payment.

“The first part of the new process is essentially the data mining the RACs have done all along using their proprietary systems, and is very similar to automated reviews,” says Kimberly Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc.

“The only exception being that identified claims only contain possible errors, rather than assumed errors, as in a standard automated review,” she says.,

The second part includes a notification letter sent to the provider explaining the potential billing error and giving the provider 45 days to submit documentation to support the original billing, according to CMS. This is the same time frame for submitting documentation for claims selected for complex review.

Semi-automated reviews may lead to additional burdens for providers, says Elizabeth Lamkin, MHA, partner/CEO at Pace Healthcare Consulting, LLC, in Hilton Head Island, SC.

“We’ve known all along that automated reviews could turn into a complex review, and now they’ve added a formalized process,” she says. “This really emphasizes the risks of automated reviews because the RACs can scan unknown numbers of records for issues to be used for “mining vulnerabilities,” she says. “These could then become complex reviews and be used for identifying issues for extrapolation. This could be the tip of the iceberg as contractors become more sophisticated.”

Medicaid RACs are coming…someday

CMS has instructed Medicaid agencies to develop Medicaid recovery audit contractor (RAC) programs; however, the implementation date remains unknown.

CMS sent an October 2010 letter to state Medicaid directors, requiring state agencies to submit their plans for RAC implementation or request an exemption. CMS also said in the letter that it expects the Medicaid RAC programs to be fully implemented by April 1, 2011. However, a February bulletin has suspended that deadline indefinitely.

The bulletin states that the April 1 deadline did not give state agencies enough time to address operational issues to ensure compliance with provisions of the final rule, which is yet to be published. CMS plans to issue the final rule later this year and will indicate the new implementation deadline at that time.

In the meantime, you can find out which states have submitted their Medicaid State Plan amendment (SPA) to CMS, at the CMS website. SPAs address the essential elements of the state’s RAC program. To date, all U.S. states and territories have submitted SPAs.

CMS announces electronic data submission tool for providers

Editor’s note: The following post originally appeared on the Revenue Cycle Institute website.

As it currently stands, providers respond to documentation requests from review contractors such as recovery audit contractors (RACs) and Medicare administrative contractors (MACs) via mail or fax. As evidenced in the past, providers have had a number of problems with this form of coordination. Announced this week, however, is a new option that allows certain providers to make electronic data submissions.

CMS is referring to the new option as “esMD,” (electronic submission of medical documentation.) Phase one of esMD will begin in April 2011. During this phase, according to CMS, certain review contractors will continue to send medical documentation requests via paper mail and providers will have the option to electronically send medical documentation back to the contractor.

Phase two of the initiative—which CMS is hoping to implement in 2012—will entail  review contractors electronically sending documentation requests to providers when their claims are selected for review. As of now, the following review contractors are planning to participate in the esMD pilot beginning in April 2011:

• The RACs for regions A, B and D (DCS Healthcare, CGI Technologies and Solutions, Inc, and HealthDataInsights, respectively)
• The MACs for jurisdictions 1, 3, 4, 5, 9, 10, 12, 13 and 14
• The comprehensive error rate testing (CERT) contractor
• The program error rate measurement (PERM) contractor

In addition, CMS anticipates the following review contractors may be participating in the esMD pilot beginning on or before December 2011:

• The RAC for Region C (Connolly Healthcare)
• The MACs for jurisdictions 2, 6, 7, 8, 11
• The durable medical equipment (DME) MACs for jurisdictions A, B, C and D

In order to participate in the pilot of the esMD program, providers will need to use a “gateway” for information exchange. The Nationwide Health Information Network (NHIN) is a set of standards, protocols, legal agreements and specifications that a consortium of health information organizations have agreed are necessary for secure and private exchange of health information over the Internet, according to CMS. The Nationwide Health Information Network Exchange is designed to “connect a diverse set of federal agencies and private organizations to securely exchange health information,” and CMS intends to use it during the esMD pilot.

One crucial piece to transitioning to electronic submission is the selection of a gateway, which are necessary in order take part in the esMD pilot, according to Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

“Providers will need to obtain access to a CONNECT-compatible gateway,” she says. “While hospitals may choose to build their own gateway, CMS anticipates that contracting with a health information handler (HIH) that offers esMD gateway services will be the most popular choice.”

While this new development aims to help streamline internal processes, providers should consider a number of factors, Mackaman says.

“First, providers should do a cost-benefit analysis of using esMD versus mailing paper or CDs,” she says. “Facilities already have to absorb the expenses of the existing process since the current copy reimbursement rate of $0.12 per page does not cover the broad range of costs involved with processing even one request.”

Healthcare providers may also want to consider waiting until CMS works out many of the initial bugs and process changes once the phase one option goes live, she adds.

For more details visit the esMD web site at http://www.cms.gov/ESMD.

Additionally, CMS published three frequently asked questions regarding esMD.

• What is esMD?
• How do we sign up for esMD?
• Has CMS made any public presentations about esMD? Are slides/handouts available?

Revenue Cycle Institute releases 2010 RAC Preparedness Benchmark Report

The results of HCPro’s second annual “RAC Preparedness Benchmarking Report” are in, and case managers continue to be a large part of RAC preparedness efforts.

A total of 459 providers responded to the survey, representing facilities of all sizes from each of the four RAC regions.

According to the results, many facilities have had minimal contact with their RAC. More than 50% of respondents have not had recoupments related to automated audits, and nearly 40% had not received a record request for complex audit.

Despite the lack of contact with RACs, a greater percentage of facilities have a formal RAC program; 90%. That’s up 20% from 2009. More than half of the respondents (63%) have also designated a RAC coordinator. The most common background for RAC coordinators is HIM/coding (29%), followed by case management (18%).

Looking toward the future, 41% of respondents said medical necessity and one-day stays are their main focus for RAC preparations going forward. Case managers play a key role in determining medical necessity and will no doubt continue to be a large part of RAC preparation efforts.

Download the entire “RAC Preparedness Benchmarking Report” at The Revenue Cycle Institute website.

RAC talk with Kimberly Anderwood Hoy

Kimberly Anderwood Hoy, Esq., is director of Medicare and compliance for HCPro, Inc., and an expert on all things Medicare. Our sister blog, The Revenue Cycle Institute, recently sat down with her and picked her brain on several Recover Audit Contractor (RAC) topics. Notice that she mentions the fact that RACs are moving setting their sights on medical necessity, which means case managers will play a key role.

What was one of most common front-end problems hospitals may have had that led to RAC audits and/or recoupments?

I’m not sure that there’s anything specific. I think that if there’s a strong compliance plan that is looking out for errors, a facility should and can be in good standing. In other words, the best defense is a strong compliance plan.

Was there any one particular CMS-approved issue that may have given providers the most trouble this past year, and why?

If you went by the last year, there hasn’t been one particular issue, but rather a number of issues across the board.  What’s been giving providers the most trouble are the operational difficulties the RACs have been having with everything from records receipt to timing of denial notices and recoupments.

When it comes to a facility’s RAC team, is there a specific member of the team that is the most integral?

In my opinion there are a few members that are most important, and then there are other members that—if a hospital can afford it—are helpful and valuable to the team as well. I do think a compliance auditor is an extremely vital member. I also think that somebody from case management is valuable too because the majority of the errors that caused problems in the demonstration were medical necessity. In addition, you need somebody from the business office or billing area who understands the appeals process and billing aspect that can truly determine whether an error was an overpayment or an underpayment.

Speaking of payments, in your opinion, what was it about Medicare’s three-day rule that had providers in such an uproar in 2010?

The problem with the three-day payment window is that some fiscal intermediaries and MACS had misapplied it even after CMS came out with additional guidance.  The claims processing contractors were giving incorrect advice to providers and processing the claims incorrectly. Providers assumed the way the claims processing contractors were processing the claims followed the rule correctly, but unfortunately that was not always the case.  Even providers who understood the rule and billed it correctly were getting denials when they should not have been, causing them to doubt how the rule should be applied.

What type of impact do you expect RAC expansion into Medicaid to have on providers or what should providers be doing to prepare for the RAC expansion into Medicaid?

That will all depend on where providers are at.  Some Medicaid programs are much more sophisticated than others, because they have much higher populations in their states and therefore are much more fraught with errors and problems. I do think that in the end, the RAC program for Medicaid will be positive.  I think there are far more system problems and unclear guidance on the Medicaid side and as the RACs look for incorrect payments they will identify these and bring them to the state Medicaid agencies’ attention.   This may result in clarification of some issues that providers have struggled with in the past.

First it was DRG validation, then medical necessity issues – what will be the next big target of the RACs?

I thought that once the RACs started on medical necessity that it was going to be the next big thing and that would be all that we would see for a while, but they have continued to approve more automated issues. I think that by being unable to audit medical necessity issues for the beginning portion of the program they found other lucrative areas and realized that medical necessity wasn’t the only avenue for recoupment.

What is the one word of advice you’d give to providers when it comes to preparing for RACs in 2011?

My best word of advice when it comes to RACs—and I know some people may disagree—is to have a strong compliance plan and strong revenue cycle team to ensure what you are doing is correct in the first place, and let the chips fall where they may. If you focus more on getting what you are doing right and less on how the RACs will catch you on something, then you will benefit from it in the end. Hospitals truly should be taking control of their own agenda and not be driven by government auditors.

CMS takes first step toward Medicaid RAC implementation

Editor’s note: The following post originally appeared on the Revenue Cycle Institute website.

CMS released the long-anticipated proposed rule for Medicaid recovery audit contractors (RACs) Friday November 5, setting the stage for the targeted April 2011 implementation date.

The use of Medicaid RACs is another initiative put forth by CMS as part of the Affordable Care Act—implemented earlier this year—designed to identify waste, fraud and abuse in the healthcare system by reducing improper payments. According to the rule, states must establish Medicaid RAC programs by submitting state plan amendments to CMS by December 31, 2010 and fully implement their programs by April 1, 2011.

Providers now need to tighten up their processes for accurate coding and medical necessity as it relates to Medicaid as the latest RAC program begins to take shape.

“Hospitals need to be clear that the Medicaid RAC program does not replace current Medicaid auditing and program integrity efforts,” says Joe Zebrowitz, MD, executive vice president for Executive Health Resources. “The additional Medicaid program oversight only makes more clear the need to have robust and compliant real-time processes on both the medical necessity and coding fronts, as well as a structured and scaled approach to defending oneself against inappropriate intermediary denials.”

In addition to distinguishing the overall Medicaid RAC program from the Medicare RAC program, providers should take note that the appeals process will be vastly different as well. In the case of Medicare, the appeals process is laid out very clearly no matter what state you are in and you have the opportunity to present the case to an arbiter. With the Medicaid RAC program, the states manage the appeals process, therefore, there will likely be greater variance between appeals processes, state-to-state, as compared to Medicare, according to Zebrowitz.

“Providers need to prepare to manage the process and be intimately familiar with the many regulations, guidance, and interpretations pertaining to admission review,” he says. “With any of the healthcare auditing entities, it’s not enough to simply reach the correct medical necessity answer, but that answer must be reached through the implementation of a daily compliant review process. You want to have a process that is so ironclad that auditors—particularly contingency auditors—have nothing to find.”

Sara Kay Wheeler, partner at King & Spaulding LLP in Atlanta, concurs it’s crucial for providers to know the differences when it comes to Medicaid.

“The partnership between the states and CMS in administering the Medicaid program makes the program so different that while there may be some general lessons to be learned from the Medicare RAC program, the influence of state law and the intricacies of each state’s Medicaid program will make these Medicaid RACs function very differently,” she says. “When you think about how the country is carved up by the Medicare RACs, there are only four RAC contractors covering the entire nation; but with Medicaid RACs, states can contract with one or more entities, and there may be reason for states to engage companies that are the most knowledgeable with the way the state’s reimbursement rules actually work.”

So, what is the next step for providers when it comes to preparation for Medicaid RACs? According to Zebrowitz, the answer is two-fold:

“First, make sure you are as rigorous in your Medicaid admission review process as you are in your Medicare admission review process. Recognize that the rules may be different compared to Medicare and familiarize yourself with the specific differences,” he says. “Next, you’ve got to come up with a way to manage the process concurrently and to ensure you are arriving at a compliant admission status up front, and manage retrospectively to ensure your protection of rights within the potentially lengthy appeals process.”

In addition, providers should remain vigilant of updates provided by CMS and the eventual Medicaid RAC contractors, according to Wheeler.

“There is likely going to be much more legwork on the Medicaid RAC side if there are multiple contractors that the providers will need to monitor, similar to how providers currently monitor the four RAC sites to stay current on developing issues,” she says.

And as always, providers will need to ensure that they have their process in check on the front end, according to Zebrowitz:

“If our experience in the world of Medicare erroneous payment auditing is any indicator, the best defense against inappropriate payment audit denials is having a process to achieve an upfront compliant admission status certification.”

View the proposed rule here: http://www.ofr.gov/OFRUpload/OFRData/2010-28390_PI.pdf

Medicaid RACs coming soon

Editor’s Note: The following blog post was adapted from the Revenue Cycle Institute.

CMS has begun laying the groundwork for expanding the RAC program to Medicaid. The agency released an information collection form and supporting documents for contractors for Medicaid plans September 10. 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 forms list several criteria for the RAC expansion, including provisions related to:

• Payment of the Medicaid RACs
• Appeal of adverse Medicaid RAC determinations
• Coordination of Medicaid RAC activity with other reviewers and entities (e.g., the Medicaid integrity program)

According to the Federal Register, CMS created the forms to prepare for 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 the problems much as we did in the Medicare demonstration project based on a learning curve for providers and RAC auditors.”

CMS followed the information collection with letter to state Medicaid directors on RAC expansion. The letter instructs each state and territory to either attest that it will establish a Medicaid RAC program by December 31, 2010, or indicate that it is seeking an exemption from this provision.

CMS publishes RAC improper payment vulnerabilities

CMS released two additional special edition MLN Matters articles to educate providers regarding vulnerabilities identified during the recovery audit contractor demonstration project and to prevent the same problems from reoccurring.

CMS has now released three MLN Matters articles that address the following area of risk:

• No Documentation or Insufficient Documentation Submitted (July 12)
• Medical Necessity Vulnerabilities for Inpatient Hospitals (September 23)
• Diagnosis Related Group (DRG) Coding Vulnerabilities for Inpatient Hospitals (September 23)

For more information and analysis on these articles visit HCPro’s Revenue Cycle Institute.

Position your resources to prepare for RAC medical necessity audits

The recovery audit contractors (RAC) have certainly been busy lately. CMS gave permission to three RACs (Connolly, Health Data Insights (HIS) and CGI Federal) for them to begin medical necessity audits. Connolly announced that it intends to conduct medical necessity audits on the 20 DRGs it is currently focused on. View the Connolly list here.

The following are the areas CGI is targeting for medical necessity review:

• 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)
• Chronic obstructive pulmonary disease DRG 88 MS-DRG 190, 191 (Medical necessity review and MS-DRG validation)
• Respiratory 175, 176, 180-188, 192, 196-206 (Medical necessity excluded except for MS-DRG 192)
• Nutritional and metabolic disorders DRG 296 MS-DRG 640 (Medical necessity review and MS-DRG validation)
• Kidney and urinary tract infections w/MCC DRG 320 MS-DRG 689 (Medical necessity review and MS-DRG validation)
• GI disorders 368-370, 374-376, 380-390, and 392-395 (Medical Necessity Excluded except for MS-DRG 393)
• Percutaneous cardiovascular procedures MS-DRG 247, 249, 251 (Medical necessity excluded except for MS-DRG 249)
• Renal failure DRG 316 MS-DRG 682, 683, 684 (Medical necessity review and MS-DRG validation
• 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)

HDI announced that it will focus on the following areas for medical necessity review:

• DRG validation-cardiovascular, other (Medical necessity review may be performed for MS DRG 312 only)
• DRG validation-musculoskeletal disorders (Medical necessity review may be performed for MS DRGs 551 and 552 only.)
• DRG validation-blood and immunological disorders (Medical necessity review may be performed for MS DRG 811 only.)
• DRG validation-cardiovascular diseases (Medical necessity review may be performed for MS DRGs 253, 254, 291-293, 302, 308, 313-316 only.)
• DRG validation-nervous system disorders (Medical necessity review may be performed for MS DRGs 056, 057 and 069 only.)
• DRG validation-kidney and urinary tract disorders (Medical necessity review may be performed for MS DRGs 682-684 and 689 only.)
• DRG validation-endocrine, nutritional and metabolic disorders (Necessity Review may be performed for MS DRG 640 only.)
• DRG validation-gastrointestinal disorders (Medical necessity review may be performed for MS DRGs 391 and 393 only.)
• DRG validation-cardiac procedures (Medical necessity review may be performed for MS DRG 249 only.)
• DRG validation-MDC 04 respiratory (Medical necessity review may be performed for MS DRGs 190, 191 and 192 only.)

Potential Impact on Case Managers

The good news for case managers is that the RACs’ targets are not terribly surprising. If you check your hospital’s CERT and PEPPER reports you may find that some administrators have already flagged these issues.

Hopefully, your organization has been working on improving utilization in these areas. However, if you have not had the time or the staff required to focus on managing Medicare medical necessity, you may be feeling overwhelmed the additional admission reviews that you will need to complete during the initial inpatient day.

Redeploy support

Albert Einstein said insanity is doing the same thing over and over again and expecting different results. If hospitals do not modify processes to meet the increased RAC scrutiny we can not hope to protect our Medicare revenue. Adding case managers is an option, if you can find and afford them. But unfortunately that option is not open to many facilities.

Consider deploying a coder to work in conjunction with the case managers. The coder can review charts with the case managers on admission to identify the potential DRG assignment for the patient. The case manager can then work with the physician to ensure he or she documents the record to accurately support utilization and medical necessity.

If you can’t afford to move a coder, consider using coding interns and coders-in-training to work with case managers. It is a good match. Case managers can teach coders how to navigate the record and the trainees can teach case managers the rudiments of how to choose a potential DRG based on the documentation available. This collaboration should result in improved documentation.

Software

If your organization was considering case management support software, now is the time to determine the potential the return on investment. Calculate the dollar value of your potential DRG medical necessity denials. This will help you predict the return on investment on your dollars invested in software. You may be surprised that the tools pay for themselves fairly rapidly. Ask vendors for a free trial of their product. Be sure to look for brands that offer reporting capabilities important to your process.

Besides streamlining the case management process, most brands also offer electronic access to utilization data, which can enhance your case managers’ productivity and reduce denials.

Ramp Up Training

According to the Fall 2009 OIG Semiannual Fraud and Abuse Report insufficient documentation cpst the Medicare Trust Fund $2.6 million beyond the RAC findings. An additional $800,000 was wasted on medically unnecessary services and supplies.

These numbers illustrate the problem of inadequate documentation. Work with your hospital’s physician leaders and implement documentation improvement training for all medical staff. Yes, there will be an initial pushback, but process improvement in this area will reward you going forward.

Partner with Your Compliance Department

Ask your hospital’s compliance department to audit your departmental processes. Identify root causes and make changes to your work flow to mitigate losses. Request your compliance team educate case managers on the latest CMS regulations. Hospital auditors can also review your case managers’ notes to determine if there is any room for improvement with regard to Medicare regulations.

Inpatient admissions decision fuels RAC uncertainty

Editor’s Note: This post originally appeared on the HCPro’s Revenue Cycle Institute website.

Recent approval of a RAC issue for inpatient hospital claims review has initiated uncertainty, thus putting an emphasized onus on providers to lean on CMS guidance and policy manuals.

The issue, “inpatient admissions without a physician’s inpatient admit order,” can be referenced in the Medicare Claims Processing Manual, Section 50.3 where it 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 always 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 says. “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 of the things that may confound facilities is the fact 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 this point, this new 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 says.

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 give them 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,” according to 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 says. “Also, be sure to have an internal process set up for looking at 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.”