Seeking an AMA Code – and Emerging Challenges to Aetna’s MA Policy

Let me start with some follow-up on a topic I have written about before: the widening of the use of “against medical advice” (AMA) to designate patients insisting on discharge to inappropriate settings prior to the completion of their medically warranted hospital care. I had the opportunity last week to present my thoughts to the National Uniform Billing Committee (NUBC), the organization that creates billing codes and rules.

While they were sympathetic to the effort, they did not feel that developing a formal definition was within their purview, noting that the use of discharge status codes to also make transfer Diagnosis-Related Group (DRG) adjustments would be a significant barrier. But a listener to the presentation, my friend and revenue cycle expert Valerie Rinkle, suggested that the NUBC establish a condition code to designate when a patient is discharged to a setting contrary to the medical team’s advice, which could then be used by the Centers for Medicare & Medicaid Services (CMS) and other payers to exclude such admissions from quality and readmission measures.

Thankfully, the NUBC agreed to work with me and other stakeholders on exploring possible solutions to allow providers to no longer be held accountable for decisions that are totally outside their control, leading to readmissions or poor outcomes. So, stay tuned.

Next, last week was the national physician advisor conference put on by the American College of Physician Advisors, and as you might guess, the new Aetna Medicare Advantage (MA) inpatient policy was a topic of frequent conversation. Now, sadly, there was no easy solution. Dr. Joanna Kipnes from Duke presented how her health system operationalized addressing this problem, and for me, the most important takeaway was that you cannot address Aetna’s behavior if you don’t know they are doing it.

When you ask for inpatient admission, they are approving it, no questions asked. And when they send the notification to the hospital, the letter clearly states that the inpatient admission was approved. But one has to read into the body of the notification to discover that they determined the inpatient admission was low-severity and would be paid at the lower payment level.

Many utilization review (UR) staffs saw “approved” and moved on to the next case, as they do with most notifications. Your finance team must also carefully watch the payments and look for an inpatient claim paid at less than the contracted inpatient rate. Aetna is counting on these steps not happening, so please disappoint them by finding and fighting every attempt to lower your payment.

I must commend Jefferson Health for being the first to file a lawsuit against Aetna for their policy. Now, since our legal system moves slower than rush-hour traffic in Los Angeles, we may not have a decision for a long time, but perhaps if enough providers file suit, the legal costs will lead Aetna to reconsider their policy.

Finally, the 2027 Inpatient Prospective Payment System (IPPS) Proposed Rule is out, and two notable proposals are to remove the complication and comorbidity (CC) designation for all homelessness codes and for the Comprehensive Care for Joint Replacement bundled payment program to go national starting in 2027. Neither one is good news, but I will have to leave the details for another article.