A Physician Advisor’s Plea: Ask More Questions!

Can we talk for a moment? As an educator, I’m obligated to insist that there are no stupid questions. As a physician advisor who works with leaders in case and utilization management who have been immersed in and attuned to rules and regulations from the Centers for Medicare & Medicaid Services (CMS) for multiple years, I desperately insist folks ask more questions.

According to the real-time counter I urged Dr. Ronald Hirsch to add to his website years ago, as of this writing, the Medicare Two-Midnight Rule is 4,003 days, 9 hours, 22 minutes, and a few seconds old. A bit less forgiving is the age of the CMS mandate to Medicare Advantage (MA) plans, that they must follow the Two-Midnight Rule, effective Jan. 1, 2024.

But still!

Despite many years and months and countless educational webcasts, articles, and presentations given by experts in the field – many associated with MedLearn Media and the American College of Physician Advisors – people are not just confused, but actively misinformed.

As someone who has developed, refined, and optimized the physician advisor role at multiple hospitals and health systems across the country (the first being my own, when I was recruited into a position that had never before existed), escalating discoveries of poor regulatory advice gives me heartburn. True, Festivus is still two months away, but I need to air out my grievances. It causes me near-physical pain (see aforementioned gastric reflux) to witness very smart people being led down a briar patch of regulatory slight-of-hand while wearing improved reimbursement-tinted glasses.

So, let’s review the top offenses.  I got a lot of problems, and now you’re gonna hear about it!

1. The crux of the Medicare Two-Midnight Rule involves passage or anticipated passage of two midnights in the hospital due to the patient’s need for services that can only be rendered in the hospital setting – not simply the passage of two midnights. Can determination of medical necessity for that second midnight be tricky? Absolutely. This is where physician advisors, exquisite documentation from clinicians, and a realistic eye on outpatient services comes in. For the love of Athena, stop asking for an inpatient order every time hospital day three is approaching. 
   
   
2. “Difficulty performing activities of daily living” is not a medical condition requiring hospital care. Full stop. Similarly, listing every complaint and mildly abnormal lab value for a patient remaining hospitalized for a second midnight doesn’t support medical necessity of continued hospitalization. Documenting that the “patient will require a second midnight of hospital care for constipation and leukocytosis” does not cut it without further explanation.
   
   Patients are constipated at home every day; what is it about this patient’s condition that requires hospital care? Leukocytosis is an extremely generalized term, without more specificity, about the severity of the increased white blood cell level or suspected reason for the increase. Please do not think inpatient status will be justified by the Medicare Two-Midnight Rule if your physicians document any condition in a patient passing a second midnight.  
   
   
3. It’s often a fallacy to assert that there’s a higher financial burden for the patient if they’re not discharged in inpatient status. Outpatient hospitalization involving observation services can be less expensive for the patient than an inpatient hospitalization, depending on the circumstances.
   
   The Medicare Part A deductible of $1,676 is the patient’s responsibility for every inpatient hospitalization if more than 60 days have passed. Meanwhile, the Medicare Part B deductible for outpatient hospitalizations (with or without observation services) is $257 and paid only once a year.
   
   Granted, “observation stays” also involve a 20-percent co-pay, but this can still be significantly less than an inpatient hospitalization, considering that the observation services code, APC 8011, is a charge of $2,607.99, which would be just $521.60 for the patient.
   
   
4. Status can be compliantly changed until the patient’s “discharge is effectuated,” but there’s no CMS definition as to what this means. To equate it with physically leaving the hospital or hospital unit is a squishy assumption, at best. Opinions vary widely, but in general, your marker should be consistent, reliably timed in the chart, and agreed upon by your compliance team.

These common misconceptions and misguidance promise increased hospital margins and case mix index (CMI) but actually wreak havoc on utilization review efforts and lead to massive increases in MA denials. 

Now, then. Who’s up for a wrestling match?