CoP Compliance in the Face of COVID 19: No Time to Cut Corners: Part 2

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Original story posted on: November 18, 2020

Now more than ever it’s no time to cut corners.

EDITOR’S NOTE: This article is an expansion of the original piece, “CoP Compliance in the Face of COVID-19: No Time to Cut Corners,” originally published April 1, 2020.

Recent articles by Marie Stinebuck, Edward Hu, MD, and Stefani Daniels touch on important issues facing hospital providers in this trying time, and I’d like to add my frontline support.

For what it’s worth, I have never gotten too wrapped around the axel of length of stay (LOS). In a nutshell, too short of a hospital stay can have a detrimental impact on readmission risk. If a physician makes the case in their documentation for continued stay, then it falls to coders to exploit every legitimate opportunity to capture the highest-paying DRG – not a difficult task under MS-DRGs, when combined with ICD-10-informed documentation and clinical documentation improvement (CDI).

Marie Stinebuck elegantly described in a few words the questions bundled payment and Accountable Care Organization (ACO) providers must ask of themselves. It’s a complicated dance to be choreographed carefully. Despite the current pitfalls precipitated by the COVID-19 public health emergency (PHE), alternate payment models are the future, as long as they are partnered with alternate delivery systems. For example, the Medicare Care Choices Model for hospice care does not require hospital providers and medical groups to reinvent the wheel or place themselves at financial risk. Instead, it offers a common-sense alternate delivery system using something already in place.

Dr. Hu rightly points out that even with prior authorization in hand, post-acute providers are often unable to readily accept new patients due to their own PHE stressors. We may disagree, however, on the need for waivers to save us. The withdrawal of post-acute care prior authorization waivers by commercial payers only takes us back to the obstacles we encountered in the time before COVID. Recent events did not create the problems in our so-called health system, but have sped de-evolution and shone light on problems that too long went unaddressed.

I believe we have at our disposal compensatory strategies to overcome utilization, cost, and LOS management challenges, as well as the lack of federal engagement in managing Medicare managed care.

It’s time to make transitions-of-care planning fully a part of utilization management (UM), now more than ever, when throughput is paramount, by anticipating such needs beginning on the first day of a stay. Here’s where I’m going with this:

  • Medical necessity is positively and negatively affected by resources and barriers to optimal wellness and self-management. This has to be taken into account in determining if one more day or an early discharge represents the optimal LOS.
  • MCG and InterQual make an assumption that discharge planning is an ongoing affair. If you don’t know the final destination, it’s not easy to keep to a timetable. (I am still opposed to a slavish devotion to these two standards, or any of the recent AI-based tools.)
  • Working on the first day of an inpatient stay toward a transitions-of-care plan can greatly mitigate payer and post-acute provider barriers. If a Skilled Nursing Facility (SNF) is likely needed, locate the best providers for the specific patient and begin the prior authorization process early. Delays may still come; mitigation is key.
  • The Medicare Conditions of Participation demand an early-in-the-stay, patient-engaged approach to transitions planning. It pains me to say it, but the Centers for Medicare & Medicaid Services (CMS) got this right.

Whether dealing with LOS, denial of coverage management, or guiding an alternate payment arrangement to profitability, having trusted post-acute partners and a plan to bring patients to them at just the right time is good UM through good transitions execution.

CFOs: devote the necessary resources to transitions-of-care planning. Consider defunding the UM department in favor of a combined role. Any perceived efficiencies of remote and/or centralized UM will be exceeded by putting LOS management shoulder to shoulder with transition planning. I can get testimonials. If you have slavish devotion to anything, have it to following the spirit of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, engaging patients and honoring preferences.

Telling patients how things will be is a barrier to optimal UM; patients have to buy in to any plan for it to work.

Marvin D Mitchell, RN, BSN, MBA

Marvin D. Mitchell, RN, BSN, MBA, is the director of case management and social work at San Gorgonio Memorial Hospital, east of Los Angeles. Building programs from the ground up has been his passion in every venue where case management is practiced. Mitchell is a member of the RACmonitor editorial board and makes frequent appearances on Monitor Mondays.

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