Custodial Admissions from the ED: PART II

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Original story posted on: April 8, 2020

Health systems are grappling with custodial/social admissions from the ED.  

In my last article, I discussed how emergency departments (EDs) across the country are grappling with patients presenting without the ability to care for themselves, or others who are unable to care for them, leading to a custodial admission to the hospital. Here, I will detail the ways in which health systems are attempting to manage these situations, which can lead to patient risk health-wise, patient risk for those who require a hospital bed but cannot be placed into one due to space limitations, and financial risk for hospitals.

The most common solution involves utilizing a notice provided by the Centers for Medicare & Medicaid Services (CMS), the Advance Beneficiary Notice (ABN), if the patient is to be hospitalized as outpatient. 

  • The ABN informs the patient that a specific service may not be paid by Medicare, and that the cost of the service will be the responsibility of the patient. In order to bill the patient from the start of the custodial hospitalization, this notice must be given while the patient is still in the ED, so the patient can make an informed decision about hospitalization versus finding another possible option for care. And it should be accompanied by a clear discussion about how all charges will likely be the responsibility of the patient, since the hospitalization would be for custodial care and because the patient does not require medical services that can only be provided by the hospital. Many patients presenting to the ED with a need for custodial care have severe dementia, and a power of attorney (POA) is established. For these patients, the same process applies, informing the POA. If a POA is not physically present with the patient, the ABN can be reviewed over the phone.

  • This official notice from CMS can take some of the “blame” away from the hospital for charging the patient. Many hospitals have also reported that it commonly provides the necessary gravitas to encourage the patient and caregivers to brainstorm and come up with an alternative to hospitalization, such as temporary care in a family member’s home, with a plan to find a facility for placement in a few days, versus the prospect of paying thousands of dollars out of pocket for the hospitalization.

  • Unfortunately, the patient might also simply elect to return home, as opposed to paying out of pocket for hospitalization, even if it is determined that they will not be safe at home. This creates a very difficult situation for the medical care team, which, of course, does not want to see the patient make an unsafe decision. This is also the reason why some hospitals elect to give ABNs only in instances in which the medical team feels that the patient is safe to return home, but the patient or family disagrees.

  • The ABN requires someone from the hospital to fill out specific portions of the form, including the services that will not be covered and the approximate price of those services. In particular, Box D must list the service or services believed to be non-covered by Medicare. In the case of a custodial admission, the patient will be receiving nursing care and room and board. The billing staff should be consulted to determine how these items are listed on a claim, and how they are charged, so the correct information can be inserted on the form. The ABN cannot just be handed to the patient. It needs to be explained, and the patient should have an opportunity to ask questions. Also, it requires a decision to be chosen on the form by the patient, with a signature with the date. Given all of this, most hospitals utilize a case manager, often with the assistance of a physician advisor, to issue the notice. But many hospitals do not have 24/7 case manager coverage. As such, the prime hours when these situations arise – usually overnight – lack personnel to deliver the ABN, and so patients are hospitalized without it. This makes it impossible to charge the patient for services that have already been provided, and the hospital will provide the services without reimbursement until an ABN can be delivered.

  • Managed Medicare plans are not obligated to utilize ABNs like Medicare does. Each hospital needs to check its own plan contracts to see if they do. Additionally, commercial plans have no obligation whatsoever to utilize the ABN, and I have yet to hear of an instance in which a private plan has a method to protect hospitals from providing free care. In most instances, the hospital has no recourse from hospitalizing the patient while waiting for the insurance plan to authorize transfer to a lower-level facility or home health services.

Another option similar to issuing an ABN is a Pre-Admission/Admission Hospital-Issued Notice of Non-Coverage (HINN 1). 

  • This is another CMS form, but it can only be used when the patient will be placed into inpatient status with an order from a physician or other practitioner with admitting privileges, not outpatient, as above with the ABN. Many of the issues illustrated above come into play with the HINN 1 as well.

  • Some feel that this method is more advantageous for the hospital’s reputation than using the ABN, because the patient then has the ability to appeal to the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO), working on behalf of Medicare, and they ultimately inform the patient that Medicare will not cover the bill for services. Additionally, managed Medicare plans are obligated to utilize this form, as they cannot rescind the patient’s right to appeal to the BFCC-

  • However, planning to place a patient into inpatient status for custodial care is a tricky business. From the accepting physician’s standpoint, the patient is not appropriate for inpatient status, since the patient does not medically require hospitalization, much less two midnights of hospitalization. As such, the only way a physician could compliantly place the patient into inpatient status would be if the patient or family demands

Some hospitals forge close alliances with home health services, Skilled Nursing Facilities (SNFs), Assisted Living Facilities (ALFs), and Inpatient Rehabilitation Facilities (IRFs).

  • This allows near-round-the-clock availability for assessment and placement of patients straight from the ED, as opposed to the more common situation of facilities being unable to accept patients outside of office hours.

  • It requires agreements with facilities to accept patients without pre-authorization from managed or commercial insurance plans, or investigation into the patient’s financial ability to pay. As such, there needs to be pre-established financial support from the hospital itself for the services provided to the patient until another payor source (e.g., insurance plan or the patient) is identified. This puts the hospital at financial risk, and can be a barrier to establishing this process.

A final option, which most commonly is only available to large, usually academic, well-funded health systems, is use of what is sometimes referred to as a “hospital hotel.”

  • Patients have access to short-term, monitored, but non-specialized care in a nearby location outside of the hospital building until a long-term plan is established involving home services or transfer to another facility.

  • While this option allows quick discharge of patients out of the ED and prevents acute-care beds from filling with individuals who don’t need them, the final issue of “where will the patient go?” remains. If there is no established agreement to charge the patient for services, the hospital is still providing free care and housing for as long as it takes to find an alternative care situation that is safe for the patient, and which the patient will accept.

The first step to take when considering this situation is to identify how often it happens. Don’t assume that you have a good handle on the frequency. Many times, these patients will be hospitalized erroneously in outpatient status with observation services, because the medical staff misunderstands the concept of medical necessity in these instances. As mentioned in my previous article, a patient who isn’t safe for care in the home or care in their originating facility is not the same as a patient who requires care that can only be provided in the hospital setting. 

Next, speak with your compliance, legal, and C-suite teams about how to proceed. Is everyone comfortable with the idea of notifying patients that they will be responsible for the cost of hospitalization even if they have no other options available to them? If not, there may be disagreement with utilizing the ABN or the Pre-Admission HINN. What about patients covered by commercial plans and managed Medicare plans that don’t recognize the ABN? Is your hospital willing to create its own financial liability form and billing process for those patients to avoid revenue loss? If you believe that establishing relationships with outside facilities and/or creating a hospital hotel is the way to go, get ready for some profound planning and close collaboration between multiple departments within your health system.

Programming Note: Listen to Dr. Ugarte Hopkins report this story live during Monitor Mondays, Monday, April 13, 2020, 10-10:30 a.m. EST.

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, practiced as a pediatric hospitalist and now serves as Physician Advisor for Case Management, Hospital Utilization, and Clinical Documentation for ProHealth Care, Inc. in Wisconsin. She is Vice President of the American College of Physician Advisors.

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