The Crux of Criteria: Adhering to Standards of Care

Have you heard enough from us yet about the new Centers for Medicare & Medicaid Services (CMS) rule requiring Medicare Advantage (MA) plans to follow the Two-Midnight Rule? You have? Well, too bad, because I have more to say. Actually, the rule has more to say, and I want to be sure you are aware of some of the other provisions.

First, it bears repeating that the use of commercial criteria by MA plans is not prohibited. The plans are more than welcome to use MCG or InterQual or internally developed criteria to approve an inpatient admission. Heck, they can use their Magic 8 Ball to approve admissions. But when it comes to denying admission or other care, then using criteria as the final arbiter is not allowed, and cases require the human touch.

As I have said before, I like criteria. Yes, I know every patient is different, and no criteria set can encompass every possible patient-disease interaction, but common things happen commonly, and criteria can do an excellent job here. The other thing that criteria do is consolidate the medical literature. The standard of care should be what is optimally done for a condition, not what is done in one facility. Dr Bill Rifkin of MCG has written extensively about that variation, and it is surprising how prevalent it is.

As an example, I recently saw data from a hospital where 100 percent of their Medicare total knee arthroplasties are inpatient. That obviously stood out. It turns out that their physician’s standard practice is to keep patients at least three days. That’s the way the doctor has always done it. They like it, and their patients like the reassurance of being in the hospital, under the doctor’s and nurse’s watchful eyes.

Now, technically, under the Two-Midnight Rule, that means this physician can admit patients as inpatients based on a more than two-midnight expectation, but is that appropriate? As a review of the literature or a glance at MCG criteria, references would tell you, the standard of care is a same-day or next-day discharge for the vast majority of patients. In a case like this, a payor can rightfully use criteria to determine that this doctor may not be practicing per the prevailing standard of care. They cannot deny inpatient admission for these patients based on criteria, but the payor and the hospital know which cases need secondary review. Perhaps a review will show that this doctor’s patients are all over 90 years old, with multiple comorbid conditions, and three days of inpatient care is appropriate. Until the record is reviewed, however, one cannot know.

The same can be applied to patients with medical illnesses such as heart failure or pneumonia. It needs to be established which patients require hospital care and for how long, and which patients need that second midnight in the hospital. Not all do. And it’s not what the doctors at St. Elsewhere do with their heart failure patients that is the determining factor; it’s really about what the standard of care is.

There is a significant amount of subjectivity here, and if objective markers such as hypoxemia or mental status abnormalities are not present, the physician’s rationale must be documented to allow a reviewer to determine if it is reasonable.

It is also important to ensure that the criteria are used correctly. Some criteria sets use the terms “inpatient” and “observation,” but not necessarily in the same way that CMS does. On the second day of admission, a patient who passes observation criteria or fails discharge screening needs ongoing hospital care, and under the Two-Midnight Rule, that means they warrant inpatient admission, not extending observation past the second midnight.

Now, what if the criteria are not met? Well, CMS makes it clear in CMS-4201-F that such tools alone cannot be used by MA plans to deny care. If care is going to be denied, it must be reviewed by a physician or other healthcare professional. But more importantly, CMS will require that the person have “expertise in the field of medicine or healthcare that is appropriate for the service at issue.”

A pediatrician is welcome to approve an adult patient’s inpatient admission, but cannot deny that inpatient admission unless they have cared for hospitalized adults. An internist who has never cared for patients in an inpatient rehabilitation facility (IRF) cannot deny an IRF admission. In fact, CMS calls out IRF admissions in their discussion, noting that qualified professionals would include “a physical medicine and rehabilitation doctor, a neurosurgeon, a physical therapist or a rehabilitation nurse” – with internist and hospitalist notably absent from that list.

It is also worth noting, as can be seen in this example, that CMS considers registered nurses to be qualified healthcare professionals for such determinations – but once again, they must have the requisite expertise.
So, starting in January, if you get a denial, feel free to ask for the person’s qualifications – and if they refuse, well, then it’s time to cause some trouble.