A Potpourri of Regulatory Issues

Let me start with a topic that was discussed by David Glaser during a recent Monitor Monday broadcast. He noted the federal regulation (42 CFR 424.13) that allows an inpatient day to be considered medically appropriate and certified if the patient is waiting for a skilled nursing facility (SNF) bed, but no accepting facility has been found.  

Two things are worth mentioning. First, it does not say that an inpatient admission is appropriate simply because the patient requires care in a skilled nursing facility; it only applies to continuing an inpatient admission. That might be after a few days of necessary hospital care or after weeks of necessary care.

We still do not have permission to admit patients as inpatient simply to get them access to a SNF. In addition, this applies when there is no accepting SNF at all; if there is a bed in a SNF but the patient wants to wait for their first choice, that is not a certifiable day.

Second, as I discussed in my session at the American College of Physician Advisor’s National Physician Advisor Conference to 500 of my closest friends, there is a difference between a skilled nursing facility and a nursing facility. They are often in the same building, but the SNF portion is reserved for patients with skilled needs that meet the Medicare requirement for Part A payment as outlined in the Medicare Benefit Policy Manual, chapter 8, section 30.

The nursing facility portion is for residents receiving long term care where that is now their home. That nursing facility long term care is not what the Centers for Medicare & Medicaid Services (CMS) is referring to when the agency describes certification. In other words, you cannot certify an admission or an extra day because a patient can no longer safely live at home.

Moving on, but semi-related, is the Medicare Change of Status Notice. And we have been seeing very liberal interpretations of the need for hospital care by the Beneficiary and Family Centered Care Organization-Quality Improvement Organization (BFCC-QIO) when patients appeal, and QIO performs its review.

They are even determining that the need for ongoing hospital care is present when the physicians are documenting medical stability for discharge, but they were awaiting discharge plans to be finalized. In one case, a frail, elderly gentleman with a fall and head injury but normal imaging and normal mental status was deemed by the QIO to warrant inpatient admission because of the risk of a delayed subdural hematoma.

The physician never mentioned this as a risk, but the QIO reviewer considered it significant, so they sided with the patient in the appeal, instructing the hospital to reinstitute the inpatient admission.

Now what does this mean?

Well, I have rethought my position on how to handle those patients that present with a relatively mild acute illness but will likely be a placement issue. Many of these patients have the ability to improve with aggressive rehabilitation services.

In other words, if they get that elusive three-day inpatient stay, they can get to a SNF under Part A and their quality of life will improve.

Now it is much more complicated than I can summarize here so to understand my rationale and decide if this is something that you should consider, you can read my very long, very nuanced article on LinkedIn.

Finally, a warning.

Janelle has reported to me that Blue Cross in California has contracted with Cotiviti to audit approved inpatient admissions from four to five years ago. If Cotiviti is auditing your ancient, approved, and paid claims from any payer, don’t tolerate it.

Call your CFO, alert your contracting team, call the state insurance commission.