Hospital Impressions Remain Unchanged

Facilities widely feel that physician services are not being targeted as much as inpatient facility services, and administrators express concern regarding what appears to be a distinct bias toward Part A services.

We must remember that physicians are responsible for initiating care through expressed patient orders and supporting those services (and the selected sites of service) with adequate and accurate documentation. Part A providers are understandably frustrated when, upon retrospective review, those services are challenged and/or subsequently denied.

The Social Admissions Challenge

During our call, Cmdr. Casey referenced a practice seen across the country often referred to as "social admissions," in which a patient is admitted to a hospital on doctor's orders despite the fact that the patient does not meet CMS standard medical necessity criteria as an inpatient The purpose of these admissions often is to qualify for a subsequent Medicare-approved Skilled Nursing Facility admission. To qualify, a patient needs to remain an inpatient for three overnights.

Denials in such cases can be very costly for a hospital and not nearly as costly for a physician, which presents a problem: how can hospitals influence physicians to change their behavior when faced with these cases?

Motivation and Education for MDs

I asked Cmdr. Casey a follow-up question requesting an expanded response on her first comments.

Follow-up to Question 1: "Since physician services may or may not be audited or possibly denied in these instances (above), how might you suggest facilities educate and/or motivate the physicians to improve their documentation to protect facilities?"

Cmdr. Casey:  "First, physician claims are being audited. The MACs now also have Part B data, so the MACs may start to deny Part B services, and there are other agencies reviewing physician claims as well. Furthermore, RACs have and will be submitting proposals to review ‘issues' related to Part B claims.

Where there is a need for information, a hospital should implement their own outreach to their physicians. They need to point out that such admissions are really an unreasonable cost to everyone - there needs to be an alternative kind of service, and the physicians need to consider this before they order that inpatient admission."

While emphasizing that there are several agencies overseeing reviews of physicians' claims and pointing out that MACs now can review claims for Part B services, Cmdr. Casey simply was reminding providers of requirements already clearly stated in previously published guidelines (e.g., the ICD-9-CM Official Guidelines for Coding and Reporting). Consistent and complete documentation in the medical record must be a joint effort, and hospitals should take a more active approach in working with the physician community in that regard.

That idea, however, begs the question of how hospitals will get physicians to listen to them and change their behaviors. This was, not surprisingly, another common concern expressed to me by many providers when I was preparing for this interview.

How to Partner with the Physicians?

As further follow-up, I then asked if this "New Issues" process might be a help in this regard.

Further follow-up to Question 1: "Providers have felt that the RAC program could have been seen as a potential answer, which could bring physicians and hospitals in sync, regarding site of service and documentation reimbursement challenges that each face. Might the New Issue Review Policy you've just explained be seen as a way to help hospitals ‘partner' more with physicians?"

Cmdr. Casey: "CMS has never claimed that the RAC program will be the ‘end-all' answer program for these kinds of issues. However, from a RAC program perspective, I can't really say. There have been some education efforts to providers via the MACs about documentation, about how some inpatient procedures could safely be done as outpatient, how the MD should be sure to note in their documentation what their thought processes were, etc. CMS publishes bulletins, online articles... hopefully the physicians will see how these inappropriate services are impacting healthcare costs everywhere.

CMS does not dictate the issues the RACs will address, but CMS can approve or decline potential issues, and they will be posted on the RAC Web sites. If someone sees an issue [with how the RACs are operating], CMS wants to know immediately so we can avoid the problems seen during the demonstration project."

Commander Casey's remarks make it clear that CMS sees the education of both physician and facility providers as an important task in the efforts to reduce healthcare costs. It is also clear, however, that despite such efforts, CMS will continue to move forward with holding both physicians and hospitals accountable for medical record accuracy and contractual performance concerning reimbursement for claims they file.