Tracking Hours – For Good and Evil

Today I’ll be covering another cornucopia of topics. First, last week’s issue of Report on Medicare Compliance by Nina Youngstrom had a very interesting article that may be pertinent for physician advisors (PAs). She discussed a hospital that discovered they were paying physician medical directors for hours when they were not actually providing administrative duties.

If such a physician is still practicing clinically, that payment could be considered a Stark Law violation. I have heard that some hospitals use medical directorships as a way to reward physicians for their loyalty, and that’s fine – as long as actual work is performed. And if a violation was discovered, it would be the hospital that would get in trouble, and not the physician. But if you are a PA who is still providing clinical care, be sure you are tracking your time and specifying what work you are doing.

Moving on, Dr. John Zelem recently alerted me about a new injustice. He has been made aware that one prominent national payer is only paying admissions to critical access hospitals (CAHs) for four days of care, even if the stay exceeds that time frame and the care was all necessary. They claim since CAH inpatients are supposed to be expected to stay under 96 hours, that’s all they should pay.

Of course, that logic is senseless, but that seldom stops a payer from making such rules. Interestingly, during COVID-19, this payer stopped these payment adjustments and recoupments, because the Centers for Medicare & Medicaid Services (CMS) waived the 96-hour rule, but now that the public health emergency (PHE) waivers are all expired, they have resumed – and in fact are going back as far as May 2023 to recoup payments. It’s just amazing what crazy policies these payers are able to create out of thin air to preserve their multi-billion-dollar corporate profits.

Now, if you have a CAH in your system, it’s time to check your claims and see if any payor made unexpected adjustments or recoupments. Your revenue cycle system should be able to see the anticipated payment, per your contract, and if the actual payment differs, the claim should be flagged for review.

Finally, someone recently asked me about transfer patients and the admission order. Their hospital accepted a patient in transfer who spent two days as an inpatient at the first facility, but the inpatient admission order at the receiving hospital was not entered in the medical record until the day after they arrived, and the patient stayed a total of three days. The case manager was concerned about the sequence of events – and she was right to be.

They do have an inpatient order, and the admission complied with the Two-Midnight Rule, so they will be able to bill the inpatient admission. But if that patient needed Part A skilled nursing facility (SNF) care, they would not have had three consecutive inpatient days; the patient spent two inpatient days at the first hospital, transferred, then had one outpatient day and then two more inpatient days at the accepting hospital. Part A SNF benefit needs three consecutive inpatient days, even if at two hospitals. The CMS system is able to look at claims from both hospitals and see that there was an intervening outpatient day based on the dates placed on the claim.

But here is the thing: I would suspect that a nurse in the accepting hospital’s transfer center spoke to the doctor who approved the transfer and stated “We can accept that patient in transfer as inpatient.” Well, that is a verbal admission order that could have been transcribed into the electronic medical record (EMR) at that time, and activated when the patient arrived. Then the two claims together would have the necessary three or more consecutive inpatient days. Problem solved. So, take a look at your transfer process to ensure you don’t fall into this trap, leaving a patient with a costly SNF stay.

By the way, how are transfers like this paid? Well, each hospital prepares a claim for the care it provides. The transferring hospital indicates that the patient was transferred to another acute-care hospital in field 17 on the UB-04, and the receiving hospital indicates in field 15 that the admission source was another hospital. For the first hospital, depending on the diagnosis-related group (DRG) and the geometric mean length of stay (GMLOS), they may receive a reduced payment (many DRGs are paid the first day at two times the per-day payment equivalent, calculated as DRG payment/GMLOS, then the per diem up to a maximum of the total DRG), but the accepting hospital will get a full DRG, regardless of their length of stay.

I often hear that the DRG is “shared,” and that’s not correct.

Programming note: Listen to Dr. Ronald Hirsch live as he makes his Monday rounds on Monitor Monday, every Monday, and sponsored by R1-RCM.