Keeping Cool, Calm, and Conservative Amid the COVID Chaos: Perspective from a Frontline UM Physician Advisor

Over the past few years, our utilization management (UM) team has been hard at work to shift the habits of admitting physicians when it comes to assigning appropriate admission status.

Nothing like a pandemic to create a utilization management nightmare.

Mustering confidence amid so many unknowns associated with COVID-19 has proved challenging. Guiding providers to make the right status decision for a COVID-19 patient, considering ever-changing insurance waivers, government regulations, skilled nursing facility (SNF) closures, and the progressive and constant evolution of managing the disease itself is no small feat.

When an onslaught of patients was transferred to our hospitals from community SNFs overrun by COVID-19 – including COVID-19-negative patients – it presented a conundrum as to what their status at the hospital should be. In the heat of the moment, I became desperate. I started feverishly composing COVID-19 admission guidelines reflective of our health system’s circumstances, with the help of collegial advice inclusive of the RAC Relief listserv and my steadfast, battle-worn UM director. Of course, as you can guess, as soon as I finalized these guidelines, new information became available, prompting an update before even disseminating the initial version. Hence, I found myself in the middle of COVID-19 chaos.

But yes, I finally got ahead of the flow of information enough to publicize COVID-19 admission guidelines throughout our health system. Though in doing so, I could not help but realize the dreadful reality that the Centers for Medicare & Medicaid Services (CMS) would never pay for “prolonged observation” for these patients. My internal dialogue would not turn off. So I quickly retreated to our UM department’s mantra: stay calm, conservative, and compliant. I mustered my reserve and prepared another revision to these guidelines – one more reflective of our UM department’s true north.

I’m fortunate to be part of a large, progressive, not-for-profit health system, wherein leadership upholds high-quality and patient-centric care as being paramount; because of this, the guidelines were amended to emphasize the individuality of each patient’s admission. And on this version – given the frequency of updates to this working document – a disclaimer was added: “remember, UM recommendations may change as COVID-19 response and treatment continues to develop.”

Understanding that our health system’s main source of admissions during the COVID-19 surge is anticipated from SNFs, we devised the following list of admission recommendations:

1. 1. If COVID-19 + and symptomatic, requiring hospital level of care (LOC) = inpatient
   2. If COVID-19 + and asymptomatic, not requiring hospital LOC, but requiring chronic disease management – and could not be returned to a prior living situation (i.e. SNF) until negative COVID-19 test = observation. Discharge when medically cleared and no longer requiring hospital LOC – patient will remain in hospital until discharge disposition can be arranged.
   3. If treatment initiated for COVID-19 + requiring monitoring, even though not significantly symptomatic = inpatient
   4. COVID-19 negative but patient under investigation (PUI) due to highly suspicious symptoms = probably inpatient, depending on severity of symptoms and need for treatment
   5. COVID-19 negative and asymptomatic but brought to ER due to COVID-19 + close-contact exposure (i.e. roommate, family member, facility staff) = OP in bed if unable to send back to previous living situation (i.e. SNF) until second COVID-19 test is negative if indicated

I would like to tell you that these recommendations are infallible, and we have no UM issues, but, our physician advisors and UM team battle daily to prevent the attending physicians’ temptation to admit everyone, whether COVID-19 + or PUI, as inpatients. So far, these COVID-19 admission guidelines work best for our health system, and help us in our efforts to be compliant. I welcome your use of them also. Please feel free to tailor or dismantle the guidelines, but remember that they are fluid, and I reserve the right to change them due to our new normal: COVID-19 chaos.