Master the upcoming ICD-10 code and IPPS changes! Prepare your team for the upcoming changes taking effect on October 1. Discover the benefits of IPPSPalooza and how it can drive your success. Click here >

The advent of the No Surprises Act Brings Renewed Focus on Medical Necessity

A recent study showed that some common orthopedic procedures aren’t routinely supported by data.

As I am sure others will note, Jan. 1 marked the beginning of the No Surprises Act.

Let’s be clear here: achieving compliance is not a job for case management or utilization review or the physician advisor. Be aware of what your hospital and physicians are doing, but don’t let them make you responsible for the required written notices. It should not be case management’s duty to find out what the anesthesiologist charges when a patient having a scheduled colonoscopy needs to be given a good-faith estimate of all the charges.

Now, I will note that case management may become involved if a patient gets one of these notices and requests to be transferred to an in-network facility, but I don’t expect that to happen very often.

Moving on, one thing we talk a lot about is medical necessity. But what is “medical necessity?” It means something different to every person. But in the broad scheme of things, I like to think about it as “will this service provide benefit to the patient?” In some cases, it is clear: opening a clogged artery during a heart attack provides benefit. On the other hand, it is not clear that opening a clogged artery in a patient who is not having a heart attack provides benefit. And this uncertainty is the genesis of many disputes. The doctor recommends doing something, but the payor doesn’t want to pay, because the benefit to the patient is “not proven.”

The British Medical Journal just published a review article looking at the data supporting the clinical effectiveness of some common orthopedic procedures. And as you can see from the graphic in the article, where green represents proven benefit, there does not seem to be a lot of data supporting many of these procedures, including arthroscopic rotator cuff repair and lumbar spine fusion.

Now, does this mean that these surgeries don’t work? Absolutely not. The lack of data does not mean there is lack of efficacy. This review had very strict inclusion requirements. Literature reviews like this certainly have the potential to lead to many more disputes between payors and providers over medical necessity, but should also make us think twice about whether our care is truly benefitting patients.

An interesting U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) audit was published in late December, looking at a hospital in New York. This one was interesting for two reasons. The first was that this hospital was selected because, as the OIG stated, it was at high risk for noncompliance based upon its refusal to enter into a corporate integrity agreement after settling two False Claims Act cases. Second, this audit found that the hospital was correct in 94 of 100 charts audited.

A 6-percent error rate is almost unprecedented. Almost no one does that well. An audit of a Medicare Advantage (MA) plan released the first week of January showed a 65-percent error rate, by comparison. And five of the six denied charts from this hospital were short-stay inpatient denials, wherein even eight years after the advent of the Two-Midnight Rule, there is significant misinterpretation on both sides.

Despite this stellar result, the OIG still went ahead and extrapolated the result and demanded repayment. The OIG has specific rules about extrapolation, so that is permitted, but it seems to me that the punishment should better fit the offense.

Programming Note: Listen to Dr. Ronald Hirsch every Monday as he makes his rounds during Monitor Mondays, 10 Eastern, and sponsored by R1RCM.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn
Email
Print

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

Measuring CDI Performance: A Truthful Conclusion

Measuring CDI Performance: A Truthful Conclusion

Task-based, outcomes measurement versus process improvement generally does not support sustainable long-term results. I was recently asked by a chief financial officer (CFO) what other

Print Friendly, PDF & Email
Read More

Nine Elements of an Effective CDI Program

These foundational elements are essential to assure that there is a better way to improve CDI. Clinical Documentation Integrity (CDI) programs continue to evolve over

Print Friendly, PDF & Email
Read More

Leave a Reply

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

Featured Webcasts

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

The CMS Two-Midnight Rule and short-stay audits are here to stay, impacting inpatient and outpatient admissions, ASC procedures, and Medicare Parts C & D. New for 2024, the Two-Midnight Rule applies to Medicare Advantage patients, requiring differentiation between Medicare plans affecting Case Managers, Utilization Review, and operational processes and knowledge of a vital distinction between these patients that influences post-discharge medical reviews and compliance risk. Join Michael G. Calahan for a comprehensive webcast covering federal laws for all admission processes. Gain the knowledge needed to navigate audits effectively and optimize patient access points, personnel, and compliance strategies. Learn Two-Midnight Rule essentials, Medicare Advantage implications, and compliance best practices. Discover operational insights for short-stay admissions, outpatient observation, and the ever-changing Inpatient-Only Listing.

Print Friendly, PDF & Email
September 19, 2023
Secondary Diagnosis Coding: A Deep Dive into Guidelines and Best Practices

Secondary Diagnosis Coding: A Deep Dive into Guidelines and Best Practices

Explore comprehensive guidelines and best practices for secondary diagnosis coding in our illuminating webcast. Delve into the intricacies of accurately assigning secondary diagnosis codes to ensure precise medical documentation. Learn how to navigate complex scenarios and adhere to coding regulations while enhancing coding proficiency. Our expert-led webcast covers essential insights, including documentation requirements, sequencing strategies, and industry updates. Elevate your coding skills and stay current with the latest coding advancements so you can determine the correct DRG assignment to optimize reimbursement, support medical decision-making, and maintain compliance.

Print Friendly, PDF & Email
September 20, 2023
Principal Diagnosis Coding: Mastering Selection and Sequencing

Principal Diagnosis Coding: Mastering Selection and Sequencing

Enhance your inpatient coding precision and revenue with Principal Diagnosis Coding: Mastering Selection and Sequencing. Join our expert-led webcast to conquer the challenges of principal diagnosis selection and sequencing. We’ll decode the intricacies of ICD-10-CM guidelines, equipping you with a clear grasp of the rules and the official UHDDS principal diagnosis definition. Uncover the crucial role of coding conventions, master the sequencing of related conditions, and confidently tackle cases with equally valid principal diagnoses.

Print Friendly, PDF & Email
September 14, 2023
2024 IPPS Summit: Final Rule Update with Expert Insights and Analysis

2024 IPPS Summit: Final Rule Update with Expert Insights and Analysis

Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY24 Inpatient Prospective Payment System (IPPS) Final Rule, including new ICD-10-CM/PCS codes, plus insights, analysis and answers to questions from the country’s most respected subject matter experts.

Print Friendly, PDF & Email
2024 IPPS Summit Day 3: MS-DRG Shifts and NTAPs

2024 IPPS Summit Day 3: MS-DRG Shifts and NTAPs

This third session in our 2024 IPPS Summit will feature a review of FY24 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by senior healthcare consultant Laurie Johnson, with bonus insights and analysis from two acclaimed subject matter experts

Print Friendly, PDF & Email
August 17, 2023

Trending News