Issues Arise When They Can’t Live at Home

One of the most frustrating situations faced by physicians and case managers is the patient who can no longer live independently. Most of these patients got to that point in their lives over a prolonged period of decline, and they either refuse to admit that they need help until it is too late, or their family tries its best, but never thought to make contingency plans.

Unsurprisingly, most of these people turn to the hospital at this time of crisis. And the help they expect is that the patient will be admitted as an inpatient and kept for at least three days so they qualify to be transferred to a nursing home and have Medicare pick up the tab.

I’ll admit that I did exactly that several times in the distant past, because back then everyone did it and no one questioned it. And as I think back, I don’t think I ever really knew the rules; we knew three days were needed, but that’s all. But that was then and this is now. So why can’t we just admit these patients and keep them three days? Well, there are actually four hurdles that must be overcome.

Hurdle No. 1: Necessity for Hospital Care

First, the patient must require hospitalization. Medicare says, “the crux of the medical decision is the choice to keep the beneficiary at the hospital in order to receive services or reduce risk, or discharge the beneficiary home because they may be safely treated through intermittent outpatient visits or some other care.” Patients who are unable to live at home in general do not require hospital care at all; they would be perfectly safe at home if they had someone to take care of them or they could go directly to a nursing home, where there is staff to care for them.

Hurdle No. 2: Inpatient Admission

If we do hospitalize the patient, the next hurdle is that in order to admit them as an inpatient, there must be an expectation that they will require at least two midnights of necessary hospital care. Perhaps we can justify one midnight to look for infection or a metabolic derangement that is causing their decline, but typically, not two or more midnights. That’s the new reality that we have all faced since Oct. 1, 2013, and the new exception for physician judgment certainly does not apply here.

Hurdle No. 3: A Three-Day Stay

But let’s say we do think they will need two midnights and warrant inpatient admission. That is still not enough, because to qualify for Part A payment of their nursing home stay, they must have an inpatient admission of three or more consecutive days – and that is unlikely. The Medicare Benefit Policy Manual says that a three-or-more-day admission would not qualify for coverage only if it is a substantial departure from normal medical practice, and keeping a patient for three days to get qualification for a paid nursing-home stay would certainly represent such a departure. In fact, Medicare reports three-day inpatient admissions that lead to a nursing home stay on the Program for Evaluating Payment Patterns Electronic Report (PEPPER) as an error-prone area.

Hurdle No. 4: Skilled Needs

But even if the patient does stay three days and goes to a nursing home, Part A coverage is only available if the patient has skilled needs. And the reality is that most of these patients have purely custodial needs. When a patient is admitted to a nursing home, the staff completes the minimum data set, the results of which assign the patient to one of five resource utilization group (RUG) categories. If a patient falls into one of the higher RUG categories, it is clear they require skilled care. But that is not true for those patients who fall into the lowest RUG category. In fact, in a 2016 report, Palmetto noted that 60 percent of patients in the lower-level RUGs did not have skilled needs. How many nursing homes will be willing to accept a patient knowing there is a 60 percent chance they won’t get paid?

What is the solution? I wish I knew. As I noted, these patients rarely have a sudden deterioration, but rather there is one more straw that breaks the camel’s back. But patients and families never know to start planning ahead when the basket is half-full of straws. There are organizations such as senior services that can help; perhaps they need to conduct more outreach to primary care physicians to increase awareness and start planning earlier in the process. Perhaps these organizations need to develop SWAT-like teams to respond when a patient needs immediate assistance, either at home or at the hospital.

But I do know that as much as we want to help patients, we cannot admit all of them as inpatients. We will find and offer the available resources, provide options to patients and their families, and often keep the patient for days to weeks to obtain Medicaid coverage or guardianship. It’s just one of those obligations to our communities that we would rather not have to face – but until there is a better solution, we will continue to face it with compassion and dignity, yet not with gaming the system.


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).

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Mastering Good Faith Estimates Under the No Surprises Act: Compliance and Best Practices

Mastering Good Faith Estimates Under the No Surprises Act: Compliance and Best Practices

The No Surprises Act (NSA) presents a challenge for hospitals and providers who must provide Good Faith Estimates (GFEs) for all schedulable services for self-pay and uninsured patients. Compliance is necessary, but few hospitals have been able to fully comply with the requirements despite being a year into the NSA. This webcast provides an overview of the NSA/GFE policy, its impact, and a step-by-step process to adhere to the requirements and avoid non-compliance penalties.

Mastering E&M Guidelines: Empowering Providers for Accurate Service Documentation and Scenario Understanding in 2023

Mastering E&M Guidelines: Empowering Providers for Accurate Service Documentation and Scenario Understanding in 2023

This expert-guided webcast will showcase tips for providers to ensure appropriate capture of the work performed for a visit. Comprehensive examples will be given that demonstrate documentation gaps and how to educate providers on the documentation necessary to appropriately assign a level of service. You will gain clarification on answers regarding emergency department and urgent care coding circumstances as well as a review of how/when it is appropriate to code for E&M in radiology and more.

June 21, 2023
Breaking Down the Proposed IPPS Rule for FY 2024: Top Impacts You Need to Know

Breaking Down the Proposed IPPS Rule for FY 2024: Top Impacts You Need to Know

Set yourself up for financial and compliance success with expert guidance that breaks down the impactful changes including MS-DRG methodology, surgical hierarchy updates, and many new technology add-on payments (NTAPs). Identify areas of potential challenge ahead of time and master solutions for all 2024 Proposed IPPS changes.

May 24, 2023

Trending News