The World is My Ashtray: Understanding the Utilization Review Process

The unlikely metaphor of cigarette butts for the UM process.

One morning as I was playing golf, my golfcart mate Mike, was looking at the grounds as we drove by. Golf courses in Florida have some of the most phenomenal landscapes, quite different and unique. There tends to be water everywhere and unusual wildlife especially with the occasional alligator sighting. Northern Florida is somewhat different from central and southern Florida when it comes to those views. In the area of coastal central Florida, there is an ornamental grass called “sawgrass” everywhere. The density of this plant is dependent on the stage of trimming of the growth. When thick, a poorly shot golf ball seems to disappear.

As we traveled along between shots and the golf holes, we saw litter: empty cups, wrappers, napkins, cup covers, straws, and more. We also saw food garbage: banana peels, orange peels, and the like. Mike made the comment to me that littering like that was unnecessary and uncalled for. I did agree but stated that the food garbage over time is biodegradable, but not the rest of what we saw. Those biodegradable items over time tend to decay and become good fertilizer as one might see in a compost pile.

He agreed and then said: “yeah, but have you seen the large number of cigarette butts all around, especially in front of our buildings?” I did have to agree, though, but that I hadn’t paid attention to what he was referring to. Yet I did say that I found it pretty disconcerting when they were discarded especially on a green or tee box. Certainly,  his observations were correct. He then emphatically said: “I don’t get it; do they think that the world is their ashtray?” I immediately reacted and said: “Mike, thanks. You just gave me the title of my next talk!!” Hence, the idea was born; “The world is my ashtray!”

Let’s analyze this concept a little further. Cigarette butts are garbage, pure and simple. There is no known redeemable quality to them (but wait till later in this article). We truly know where they come from and what they are the result of. That’s pretty simple. They are the end result of smoking a cigarette or cigar and are not biodegradable where they lie. Now, there is a company “Terracycle” [1] that has found a way to recycle them into useable products, but that will talked about later. Also, this is not a statement about the positives and negatives of smoking. It’s all about the end product and “the world is my ashtray”.

You might be thinking, smoking, ashtray, pretty dirty and disgusting. True, but I will use this analogy in regard to the healthcare industry, specifically the Utilization Review (UR) process. It will involve the multifactorial role/process between Utilization Review Specialists and physicians.

Background

There is a long-standing recommended process for Medicare involving Utilization Review and reviewing for level of care and medical necessity. In view of the pandemic CMS has waived the entire utilization review condition of participation – Utilization Review (UR) at §482.30.  This regulation requires that a hospital must have a UR plan with a UR committee that provides for a review of services furnished to Medicare and Medicaid beneficiaries to evaluate the medical necessity of the admission, duration of stay, and services provided. These flexibilities may be implemented so long as they are not inconsistent with a state’s emergency preparedness or pandemic plan. Removing these administrative requirements will allow hospitals to focus more resources on providing direct patient care.[2] Hospitals must be careful though as this waiver is not a free pass to just forget about the process and bill all as IP, as audits will occur after the pandemic is over and the False Claims Act[3] has not been waived.

Here is a typical scenario in the UR process. When a patient enters the hospital and once the attending physician has written an order for level of care, IP vs. OBS, at some point there is an initial utilization review that should be done. The earlier this is done, the better. This is typically done by a case manager applying commercial criteria, Milliman and InterQual are the most common. Physician documentation is critical to this review process though that documentation is not always complete or present in a timely manner. If the patient meets IP criteria, it is generally considered de facto evidence for IP as most screening tools are rather stringent. If the patient does not meet IP criteria, one of several actions occur:

• The Case Manager will speak with the attending physician and/or
• The case is referred to a Physician Advisor for a Second Level Review (SLR)

When trying to contact and talk to the attending the case manager may run into one of several scenarios:

1. Successful discussion – probably happens more often than thought
2. The curmudgeon – www.dictionary.com defines a curmudgeon as a “bad-tempered, difficult, cantankerous person…”. That was me and it was not uncommon for me and others to say “…and what medical school did you go to?” Usually did not result in a very productive conversation.
3. The runner – this is the doc who starts walking down the hall and spots a case manager ahead. They are thinking ‘they want to talk with me’ and run off into another direction. I’ve even seen them run into the OR, and they weren’t even a surgeon.
4. The invisible man/woman – this is the doc who makes rounds at 6 AM or after 9 PM just so they didn’t have to see a case manager or discuss the case with anyone
5. The evader – in today’s world of technology with various devices, texting, cell phones and more ways to communicate this person is not seen as much. Yet they do have ways of ignoring calls and texts or saying, “I never got it.”
6. The sneak – there are some facilities that do not require the attending to do a discharge summary for patients in Observation. I am guilty of being a sneak. When ready to discharge an IP, I would change the status to OBS and then write the discharge order. That way the case manager could not have time to talk with me about the change. Back then I didn’t realize the consequences to the beneficiary financially and maybe wouldn’t have cared. (Yes, I was a case UR nightmare.)
7. The pleaser – essentially this is the doc who says that he/she will do what is asked and then goes ahead and does whatever they want
8. The collegiate – this is the doc where there is actually a great conversation and give the information needed for an appropriate level of care or referral to a Physician Advisor.

 In today’s world with there being more Physician Advisors (PA) around, they may run into similar situations but not as many. Physicians can’t play as many tricks when it is a peer they are talking with. Docs behave better then, but not always.

Reasons for not using Ashtrays

There can be many reasons why the cigarette butts don’t end up in an ashtray. Here are some:

• There are none nearby
• They are not the ones to clean up
• It’s only one (butt)
• I’ll just flip it because I’m done, happens without thinking
• They really don’t care or are lazy

What are some of the reasons why patients don’t end up in the correct status, level of care?

• No SLR is done when indicated
  • PA not available or facility does have one
  • One is not requested
• Use OBS screening with OBS order or when patient doesn’t meet IP criteria
• No UR done on weekends, holiday, and/or or evening
• ‘I know that payer is going to deny it regardless’
  • That way there is no denial to worry about
• CM “judgement”
• Shouldn’t all of the symptom DRG’s always be OBS

The Meaning of the Analogy

 OK! With an of that background given and an explanation of the UM/UR process, how does the analogy fit in? Quite simple: treating this UR process like garbage is like littering in your own backyard. Unfortunately, there are UR folks, physicians, and executives who don’t understand or respect this process as it exists. Would you throw cigarette butts or allow someone else to throw them in your backyard? Why not? First of all, it’s gross and secondly you would have to clean it up.

Treating the UR process like garbage and ignoring it during this pandemic waiver leads to a “mess” that will need to be cleaned up eventually. It needs to be cleaned up by you or someone else. It may even be some governmental agency such as the OIG, DOJ, or others. There may also be some significant fines associated with this cleanup process, having a poor process. As you know there are fines for littering. This “garbage” thinking affects everyone, especially the patient.

People who throw cigarette butts wherever they want, knowingly, or unknowingly, are displaying a sense of entitlement and a disregard for others. Maybe this sounds a little harsh on those who discard cigarette butts, but it is not considered harsh on those who abuse the UR process, especially out of ignorance or for financial gain. I will admit that the UR process may be complicated and multifaceted, but there are those who are doing it properly without the need or use of workarounds or shortcuts. If one gets audited and fined, all that can be said is that we are where we are based on our actions and choices. Said differently, there are those who are creating a “dirty” environment for the rest of us.

Why do we have anti-littering laws? From a sociological perspective there a few reasons for the existence of these laws. First, laws and their associated consequences, are meant to act as a deterrent to bad behavior. Secondly, laws provide society a mechanism by which to compensate victims or punish wrongdoers. Thirdly, laws are supposed to support rehabilitation of offenders. Society needs anti-littering laws because people fail to police themselves and their behaviors and need a deterrent from breaking this societal rule and consequences if they do so.

 UR laws exist for the same reasons. These rules and regulations prevent abuse of the system and the dreaded healthcare ‘f’ word – “fraud”. To be clear, the governmental definition of fraud is ‘reckless disregard.’ That means someone knew something was wrong and did it anyway. Because healthcare doesn’t police itself very well, the government stepped in and created rules and regulations to force us to hold ourselves accountable. In today’s world of open information and readily available rules and regulations, there is no excuse to claim ignorance of UR process or acknowledgement of the waiver. While the regulations may be complicated, potentially more so than necessary, they can be followed.

There is another new way to deal with non-ashtray butts. In the cigarette world, it’s called recycling. In the UR world it is called correcting wrong doings.

Recycling (AKA – Doing the Right Thing)

Now that the problem is defined, there needs to be a solution. A huge new solution to dealing with cigarette butts is recycling. There is a company with the website www.terracycle.com that has been able to take those collected butts and recycle them into real useable products. Recently, you may see these collection receptacles in smoking areas, especially as there is a significant rise in no-smoking.

There are solutions, also, to “recycle” the UR dilemma and it really is quite simple – follow the correct process. One would think that it should be easily implemented. To put it in simple terms, one should take their eyes off of short-term gains and focus on long term vision.

Ensuring a compliant and effective UR process involves all these elements:

• Education
  • UR staff
  • Physicians
  • Executive level
• 7 day/week UR coverage
  • Not necessarily focused on discharge planning but on medical necessity documentation and accuracy
• Timely initial reviews
  • This can vary from institution to institution depending on the culture. Finding the appropriate window for review, whether that be between 12 and 24 hours or between 8 and 16 hours depends on the documentation habits of the physicians and the availability of supporting evidence, like lab results and imaging.
• Timely re-reviews as needed
• Physician Advisor
  • Internal
  • Outsourced
• Knowledge of
  • Medicare regulations
  • Commercial payer contracts
• Understand Condition Code 44
  • And how to bill compliantly if the Code 44 process is not completed
• Understand consequences to the beneficiary
  • Medicare
  • Commercial payer

Remember: when the student is ready, the teacher will appear! Do it right the first time and recycle when needed

[1] https://www.terracycle.com/en-US/

[2] https://www.healthleadersmedia.com/covid-19/not-so-fast-consider-using-cms-covid-19-utilization-review-waiver

[3] https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts/False-Claims