Over the past few years, our utilization management (UM) team has been hard at work to shift the habits of admitting physicians when it comes to assigning appropriate admission status.
Nothing like a pandemic to create a utilization management nightmare.
Mustering confidence amid so many unknowns associated with COVID-19 has proved challenging. Guiding providers to make the right status decision for a COVID-19 patient, considering ever-changing insurance waivers, government regulations, skilled nursing facility (SNF) closures, and the progressive and constant evolution of managing the disease itself is no small feat.
When an onslaught of patients was transferred to our hospitals from community SNFs overrun by COVID-19 – including COVID-19-negative patients – it presented a conundrum as to what their status at the hospital should be. In the heat of the moment, I became desperate. I started feverishly composing COVID-19 admission guidelines reflective of our health system’s circumstances, with the help of collegial advice inclusive of the RAC Relief listserv and my steadfast, battle-worn UM director. Of course, as you can guess, as soon as I finalized these guidelines, new information became available, prompting an update before even disseminating the initial version. Hence, I found myself in the middle of COVID-19 chaos.
But yes, I finally got ahead of the flow of information enough to publicize COVID-19 admission guidelines throughout our health system. Though in doing so, I could not help but realize the dreadful reality that the Centers for Medicare & Medicaid Services (CMS) would never pay for “prolonged observation” for these patients. My internal dialogue would not turn off. So I quickly retreated to our UM department’s mantra: stay calm, conservative, and compliant. I mustered my reserve and prepared another revision to these guidelines – one more reflective of our UM department’s true north.
I’m fortunate to be part of a large, progressive, not-for-profit health system, wherein leadership upholds high-quality and patient-centric care as being paramount; because of this, the guidelines were amended to emphasize the individuality of each patient’s admission. And on this version – given the frequency of updates to this working document – a disclaimer was added: “remember, UM recommendations may change as COVID-19 response and treatment continues to develop.”
Understanding that our health system’s main source of admissions during the COVID-19 surge is anticipated from SNFs, we devised the following list of admission recommendations:
I would like to tell you that these recommendations are infallible, and we have no UM issues, but, our physician advisors and UM team battle daily to prevent the attending physicians’ temptation to admit everyone, whether COVID-19 + or PUI, as inpatients. So far, these COVID-19 admission guidelines work best for our health system, and help us in our efforts to be compliant. I welcome your use of them also. Please feel free to tailor or dismantle the guidelines, but remember that they are fluid, and I reserve the right to change them due to our new normal: COVID-19 chaos.
I receive a lot of newsletters every morning to help me stay abreast of what is happening in the healthcare industry. A troubling recent trend
EDITOR’S NOTE Day 3 of the federal shutdown continues. This article by Mark Spivey is part of a special section today published by RACmonitor and
Please log in to your account to comment on this article.
Gain clarity and confidence in OB‑GYN coding with this expert‑led webcast featuring Stacey Shillito, CDIP, CPMA, CCS, CCS‑P, CPEDC, COPC. You’ll learn how to apply global maternity package rules accurately, select the right CPT codes for procedures and visits, and identify documentation gaps that lead to denials. With practical guidance and real examples, this session helps you strengthen compliance, reduce audit risk, and ensure accurate reimbursement for women’s health services.
Uncover essential coding insights with nationally recognized coding authority Kay Piper, RHIA, CDIP, CCS. Through ICD10monitor’s interactive, on‑demand webcast series, Kay walks you through the AHA’s 2026 ICD‑10‑CM/PCS Quarterly Coding Clinics, translating each update into practical, easy‑to‑apply guidance designed to sharpen precision, ensure compliance, and strengthen day‑to‑day decision‑making. Available shortly after each official release.
Uncover critical guidance on the ICD-10-CM/PCS code updates. Kay Piper reviews and explains ICD-10-CM/PCS coding guidelines in the AHA’s fourth quarter 2026 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Uncover critical guidance on the ICD-10-CM/PCS code updates. Kay Piper reviews and explains ICD-10-CM/PCS coding guidelines in the AHA’s third quarter 2026 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Federal auditors are intensifying their focus on inpatient psychiatric facilities, using advanced data analytics to spotlight outliers and pursue high‑dollar repayments. In this high‑impact webcast, Michael Calahan, PA, MBA, Compliance Officer and V.P., Hospital & Physician Compliance, breaks down what regulators are really targeting in IPF-PPS admissions, documentation, treatment and discharge planning. Attendees will learn practical steps to tighten processes, avoid common audit triggers and protect reimbursement and reduce the risk of multimillion-dollar repayment demands.
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
BLOOM INTO SAVINGS! Get 25% OFF during our spring sale through March 27. Use code SPRING26 at checkout to claim this offer.
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
