Is this a familiar scenario to you? Patients come to the ED, although some do not even need an ED level of care. Some do, and can later be discharged. Some need to stay.
Today I want to focus on those who stay and require more care than they can obtain at their home or at the physician office. That care could still be outpatient, in the form of observation (because we just aren’t sure yet what the major issue is), or it could be inpatient. Our physicians make that call.
The Centers for Medicare & Medicaid Services (CMS) rules are very clear in that it requires a physician determination, based on consideration of complex medical factors documented in the medical record.
Say one patient is admitted to inpatient, and then the dance begins with obtaining authorization: patient access verifies that their insurance is active and sends a Notice of Admission (NOA). Utilization management (UM) then follows the contract for the insurance company to run a screening tool and send communication to the insurance company on reason need and a screening tool. And if there is any possibility of a readmission, there is more work to be done on both sides.
Have we stopped to think about the work we are doing? Do any of you want to take a timeout and think about what we need to accomplish here?
During the height of the COVID-19 pandemic, many insurance companies took their lead from CMS, and since the public health emergency (PHE) allowed us to waive some UM processes, the insurance companies helped by waiving prior authorization. I am here to tell you that that process was a much-needed reprieve, and I thank every insurance company that made it possible.
I am not sure what the statistics showed as we emerged from the worst of the pandemic, but it certainly seems that the insurance companies must have thought that the hospitals were pulling a fast one during that time, because it is far more difficult now (since about late 2021 to early 2022) to obtain the authorization number we need to bill for an inpatient level of care.
And over the course of the past few years, we have really lost that human touch to some degree. I agree that portals and faxing communication is more efficient. And I know many payors would just really like access to the electronic medical record (EMR). But there are times when there is a lot of valuable information that is lost in the translation of the written word, and all too often the conversation (and medical decision-making) is not considered, because it isn’t happening. Convenient, yes, for very black-and-white cases, but those gray cases are the norm, not the exception, and so how do we do things differently?
I wonder, and I challenge all of us to consider whether it is time to change our way of doing business. Should we start meeting over virtual platforms with the insurance companies? For all the insurance contracts you hold, could you review the criteria for the Joint Operating Committee (JOC) and include the clinical teams to discuss trends you are seeing? Is it time to meet virtually with patients at the bedside, when they have a high likelihood for (or even were recently) a readmission?
How many times do we need to walk in the shoes of another? The hospital is doing its job, providing care for those who come to seek care. The insurance company is doing its job, providing screening and evaluation of the documentation in the chart to determine how to reimburse the hospital. But where does the patient fit in all of this? What say do they have? How can they become more active in their overall care (both physical and financial), in order to achieve the best outcomes?
I wonder how many hospitals call and talk on a weekly basis with their high-volume insurance companies. I mean, really talk – not just about the most recent case that they denied, but about their goals and outcomes. Partnering to create a better process on what is needed and how to get that in order to pay the hospitals (and physicians) for what they do is vital. And teach us about some of your programs that are available to your members that might keep them out of the ED and out of the hospital altogether!
The future really depends on us learning to work together.
Election Day has finally arrived – however, some physicians may not be celebrating the new 2025 Medicare Physician Fee Schedule (PFS) Final Rule that also
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently issued a report titled “Medicare Advantage: Questionable Use of Health
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