"When an order is written for ‘assign per-case management protocol' and the case manager doesn't see the patient until eight hours later, what is the status of the patient?" one Webinar attendee asked. Another attendee quickly typed a different question: "When you talk about the MD order ‘admit per-case management protocol,' and you have it in the hospital bylaws, does CMS recognize these orders written by a case manager as a legitimate status order?"

And so it went. Question after question followed during a recent one-hour Webinar on the subject of leveraging utilization review and case management as a RAC defense. The Webinar was presented by RAC University and conducted by Patricia Dear, RN, and Michele Madison. Dear is the president and CEO of eduTrax®, a healthcare education company she co-founded, and Madison is a partner in the law firm of Morris, Manning & Martin LLP.

More often than not, the subjects of utilization review and case management are underreported, taking a back seat to other RAC preparedness issues, but they were front and center during this Webinar. The questions along with related concerns sparked considerable interest in how to build a rock-solid RAC defense.

Among many questions submitted, the following are provided here as a convenient reference for RACMonitor readers.

Please note that the relevant Medicare Policy Manuals mentioned below can be found here. Furthermore, a complete list of all chapters and crosswalks for the Medicare Claims Processing Manual can be found here.

The questions below are reproduced here exactly as they were submitted during the live Webinar or were received via e-mail after the Webinar. We asked the edu-Trax® staff to provide the answers as they appeared in a transcript of the Webinar.

Wherever possible, we have listed document references for your convenience.

1.    Question: "Is it allowable to use a licensed inpatient bed for physician-ordered OP/ observation services?"

Answer: CMS guidelines address the billing ‘status' determination - outpatient/observation or inpatient - which indicates the level of care the patient requires rather than the ‘license' of the bed the patient care is delivered in. It is not uncommon in some facilities to have inpatients and outpatient observation patients in the same room. We would suggest that facilities check with their states regarding specific licensure requirements or restrictions.

2.    Question: "Please give the Medicare manual reference for billing Part B when an inpatient admission is not medically necessary."

Answer: See the Medicare Benefit Policy Manual, Chapter 6 (pages 3-6), Section 10: "Medical and Other Health Services Furnished to Inpatients of Participating Hospitals (Rev. 37, Issued: 08-12-05; Effective / Implementation: 09-12-05)

"In PPS hospitals, this means that Part B payment could be made for these services if: ...the admission was disapproved as not reasonable and necessary..."

3.    Question: "Is the ability to use CMAP logic available to all states? In Alabama we have been told by our MAC that we could not use this method."

Answer: CMS will neither "endorse nor recommend the use of any protocol," however, they have supported the use of the Case Management protocol in seven demonstration states. Although MACs (Medicare Administration Contractors) may give their opinion in specific states, that opinion would not supersede an opinion by CMS.

4.    Question: "Does a hospital need the approval of CMS to implement a CMAP program?"

Answer: No. When asked, CMS answered as follows: "CMS is not recommending or endorsing any particular protocol. To the extent that such protocols are available, the hospital is responsible for ensuring that it complies with existing payment policy ... the QIO should not suggest that CMS either endorses or recommends any specific protocol. If state law impacts the use of such a protocol, the hospital would comply with state law."

5.    Question: "When you talk about the MD order ‘admit per-case management protocol,' and you have it in the hospital bylaws, does CMS recognize these orders written by a case manager as a legitimate status order? Do they need to be cosigned? Can the writing of the order be by case management alone?"

Answer: Individuals granted the ability to write orders for patient care are limited by the state law, and to a certain extent are driven by medical staff bylaws rules and regulations. These will determine ‘who' is able to write orders, all physician verbal, status, and status change orders must be co-signed by a physician according to CMS regulations. Any individual writing orders must ensure that such action is within the scope of their license.