CMS and Discharge Planning Conditions of Participation

Hospitals are advised to offer choice to patients in terms of nursing homes, home care agencies, long-term acute-care hospitals, and inpatient rehabilitation facilities.

It has now been over 18 months since the Centers for Medicare & Medicaid Services (CMS) updated the discharge planning conditions of participation, but we still have no interpretive guidelines. I am sure that the pandemic has affected this, but as many of you know first-hand, in-person surveys have resumed, so it would sure be nice to have that guidance to know what CMS really expects from hospitals.

But the rule itself has a few things that can help, in the meantime. First, CMS talked repeatedly about honoring patient goals of care and treatment preferences. And when they talk about something with such enthusiasm, you know they are serious about ensuring it is done. So be sure your staff is talking to patients about such factors and documenting that they discussed them.

We also know that CMS expects one other big thing; once the public health emergency (PHE) ends, you better be offering choice to your patients in terms of nursing homes, home care agencies, long-term acute-care hospitals, and inpatient rehabilitation facilities, along with providing quality measures and quality data.

This leads me to an interesting question I was asked last week about the issue of patient choice. This West Coast hospital in an area with a very large Medicare Advantage (MA) population allows case managers employed by some high-volume payers to come into the hospital and meet with their beneficiaries, with consent, and they are the ones who make all the discharge plans with the patient, not the hospital case management staff.

So the question to me was this: does the payer’s case manager have to offer full choice to their own patients, or can they just offer contracted providers? While I did not immediately have a definitive answer, here is what I think.

First of all, while the hospital is free to allow the payer staff in the hospital to make these arrangements, it is still the hospital’s responsibility to ensure that the conditions of participation are met. That means that the discussions between the payer and the patient need to be documented in the medical record. Second, Medicare expects every patient to have full choice, and makes no exception in the rules or guidance for MA patients. I think the MA patient can be given the list of contracted providers, but must at least also be told that they can select any provider (but would likely be responsible for the cost if they choose a non-contracted provider). Now, how does this hospital go about ensuring that happens? I have no idea, but I’d be sure to figure it out before the PHE expires.

But this was not the only challenging issue that came up that week. A provider received a denial from their Medicare Administrative Contractor (MAC) stating that they were recouping money for “an inpatient medical necessity denial issued by the QIO (Quality Improvement Organization).”

The problem was that they got no other information. The denials person searched and searched and found nothing. They called the MAC and Livanta, the Beneficiary and Family Centered Care QIO (BFCC-QIO) that now audits all short stays and highly weighted DRGs for the nation, and they too were of no help; the MAC referred them to the QIO, who had no information.

Needless to say, they will keep pursuing an answer. But one thing came of this search. The hospital realized that when Livanta took over for Kepro this month as their BFCC-QIO, the hospital never signed a memorandum of agreement (MOA) or provided preferred mailing addresses for record requests. So one possibility is that the denial was issued because the case was selected for audit, and then either the record request never arrived at the hospital’s health information management (HIM) department, so the records were never sent, or Livanta had no valid MOA, so they had never even sent an additional documentation request (ADR).

The lesson here for the half of the country that had Kepro as their BFCC-QIO is to find out if you have a new MOA with Livanta – and if they have the correct contact information. You don’t want to have to go through what this hospital is going through.

Programming Note: Listen to Dr. Ronald Hirsch conduct his Monday rounds during Monitor Mondays, 10 Eastern,  sponsored by R1 RCM.


Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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