A Social Media Complaint Gone Wrong – And SNF Access after Surgery

Let me start with an update on a story I have covered previously. A surgeon recently took to social media to complain about being pulled out of the operating room while performing a mastectomy and breast reconstruction to talk to an insurance company medical director about getting her patient’s overnight recovery approved as inpatient care. As I discussed, this was a failure on the part of the hospital’s utilization review (UR) staff, as the surgery was approved as outpatient, and overnight recovery does not require inpatient admission.

Now, the surgeon has returned to social media, discussing the same patient. This patient came to the ED with chest pain and shortness of breath several weeks after surgery and was diagnosed with a pulmonary embolus. The surgeon was now complaining because the insurance would not approve admission. As in most cases, we have no clinical details to know the hemodynamic stability of the patient, or the test results.

As with the surgery, there is no indication that they were denying hospital care, but simply unwilling to approve inpatient admission. Perhaps the patient was hemodynamically stable, and treatment with an oral anticoagulant was appropriate. In that case, the use of observation to start treatment and monitor the patient for decompensation was appropriate. Where was the UR staff – providing this doctor proper information? Where was the physician advisor, talking to the doctor about admission status? And additionally, what does the hospital’s compliance team think about a surgeon now providing clinical information on social media that may be violating patient privacy laws? After all, how many people could identify this patient, who not only had a mastectomy, but then developed a pulmonary embolus?

But more interestingly, in the discussion on LinkedIn about this, a legal nurse consultant pointed out that the patient may have a medical liability claim if the patient did not receive proper prophylaxis after surgery. Was it really wise for this doctor to use social media and now open themselves up to a malpractice suit?    

Moving on, I recently got a request for help from a hospital. An 88-year-old Medicare patient had a total knee arthroplasty as outpatient, and on the first day following the surgery, the family said they could not take care of him at home, as the home has steps to get in the house and to the bathroom.

While I did provide this hospital some advice, most importantly, I asked how this patient could have had elective surgery without anyone having assessed their post-operative recovery needs. If this home situation was known, the patient could have been admitted as inpatient and then be able to qualify for the Part A Skilled Nursing Facility (SNF) benefit if they were not able to go home.

The hospital then stated they did not know they can do that. So, let me quote the Centers for Medicare & Medicaid Services (CMS) from the 2018 Outpatient Prospective Payment System (OPPS) Final Rule, when the agency took total knee arthroplasty (TKA) off the inpatient-only list. “We would expect that Medicare beneficiaries who are selected for outpatient TKA would be less medically complex cases with few comorbidities, and would not be expected to require SNF care following surgery.”

That means if the patient requires SNF care (and you should know this, as part of your pre-op assessment), then you can admit as inpatient for surgery. That starts the three inpatient-day clock ticking for SNF care on the day of surgery. And note that this quote also indicates that aside from the need for SNF care, CMS acknowledges that patients with medical complexity also warrant inpatient admission. This refers back to the use of the case-by-case exception for patients having scheduled surgery; they can be admitted as inpatients even if their expected length of stay is one midnight.

Just to be clear, this applies to any Medicare patient having surgery who will have a legitimate need for SNF care, but not the patient whose family brings them to the ED because they can no longer take care of them – a situation that is much more common, and still without an easy solution. CMS has opened the door a bit for cases where we, the hospital, do something like surgery that reduces the patient’s ability to remain independent. CMS allows us to admit them as inpatients, then work them hard with therapy to try to get them home, but when they can’t, the patient will have access to SNF services under Part A.

While this statement refers to total knee arthroplasty, on an Open Door Forum call soon thereafter, CMS stated that this is not limited to TKA, but also applies to all surgeries. If you have a frail Medicare patient having, for example, a non-inpatient-only hysterectomy that will likely require SNF care, you can admit them as inpatient preoperatively to qualify for SNF, if it will be needed. (Note that there is no transcript of this call, for all who want proof.) I have discussed this in the past, but it is clear not everyone has received the message, so I hope new readers will go back and look at their processes and do what’s right for the patient. One day we can hope that Congress will eliminate the 1965 rule requiring three inpatient days to access Part A SNF services, but for now, we must work with what CMS has given us.