December 7, 2016

Patient Observation and the MOON

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Editor’s Note: The following is a transcript of an appearance by the author on the Dec. 5 edition of Monitor Mondays. Since that time, there have been conflicting reports as to when the MOON is to become effective either March 2 or March 6, 2017.

For those of you who listened to the Monitor Mondays broadcast on Nov. 28, Dr. Hirsch (Ronald Hirsch, MD) provided an infographic that the Center for Medicare Advocacy has produced to help Medicare beneficiaries better understand observation services when they are in an outpatient setting.

The top of the informational page starts like this: “The Center for Medicare Advocacy is partnering with the John A. Hartford Foundation to help people caught in the web of ‘outpatient’ observation status.”

Sounded like it would be a great informational flyer, but as Dr. Hirsch pointed out, it has errors … and it may serve to make life a bit more difficult for hospitals instead of helping beneficiaries. The Center for Medicare Advocacy is also not associated with the Centers for Medicare & Medicaid Services (CMS), so please do not think this was created by a QIO (Quality Improvement Organization). It simply is a document that our hospitals will now also have to be prepared to react and reeducate our patients on. 

In an effort to avoid a big landslide of issues at our hospitals, we sent out the notice with our own "key messages" to all of our care management teams across the organization:

"Based on your condition, your care team has determined it would be best for you to stay with us for observation. Let me explain what that means and what you can expect. I am sure you are concerned about not only care, but cost. Let me assure you – Medicare will pay for your observation stay with us. You will be moving to our observation stay area. We will monitor your condition and if something changes that would require an inpatient stay, we will talk that over with you. The good news is your care will be paid for, and you should be going home in (time frame)."

We also alerted our own legal advocacy, integrity, and patient advocacy groups to keep their eyes open on any issues. We are hopeful that this proactive approach will help. We have even educated our community outreach programs to be aware of this type of information. 

So let me discuss outpatient observation for a minute or two: We all know about the two-midnight rule: if a Medicare beneficiary is expected to require (a) hospital level of care for greater than two midnights, we should admit them to inpatient. Otherwise, they should be provided outpatient services. Those who came in for scheduled or unscheduled outpatient surgery should be in the status of outpatient, in a bed, and those who come in either directly from their physician’s office or through the emergency (department) for a medical reason should be in the status of observation.

In terms of those medical patients in outpatient observation, President Obama signed into law the NOTICE Act (the Notice ofObservation Treatment and Implication for Care Eligibility Act) in August 2015. It correlates with form CMS-10611, which is called the MOON: the Medicare Outpatient Observation Notice. 

Quite a few states had already required their hospitals to notify patients of the fact that they are in outpatient observation, so it seems that CMS and the rest of the states may be behind the times. But let's credit the actual NOTICE Act with making it more complicated than it has to be. I keep being aggravated with CMS and the rules, but honestly, the idea of "after 24 hours but before 36 hours" is in the NOTICE Act. CMS did not make that up. I just do not know where the lawmakers were when they thought the process through, because that is laborious for all hospitals, no matter the size of the organization. 

We are all still waiting for the final MOON document, and CMS is keeping us all in this state of anticipation. Even this past weekend there was information that OMB (Office of Management and Budget) pre-approved the final form. If so, we should also get a notice from CMS with a timeline to implement. 

Back in August of 2015, the AHA (American Hospital Association) pleaded with CMS to give hospitals at least six months to implement. I would hope for that, but I doubt we will get that luxury.    

I have discussed our plan before, but am glad to repeat it, because if we could get everyone to do it the same way, we may even prove that standardization can come out of a bad thing! 

If we are left to the draft document that is before us, Trinity Health still plans to have the form auto-filled, but we will have three different options for the box that CMS seems to want to require we all write in: 

Our document will simply state two different reasons that Medicare beneficiaries could be in outpatient observation, and then will have a checkbox for "other." 

  • According to CMS rules, we do not expect you to require a hospital-level of care for over two midnights.
  • Your Medicare managed insurance suggests observation level of care.
  • Other:____________________________________

Our team will just need to check the correct box. We have already started working on key messages for our teams and our processes, thanks to our revenue team, which includes our patient access and patient registration taking the lead to issue the MOON. This makes better sense to us, since these departments are staffed 24/7 and will not miss any patients coming in our doors. 

I look forward to getting the process in place, because as I have maintained before, I feel this is the correct way to educate patients and provide informed consent. 

They should absolutely be informed of their status before they are counted in our "head in the bed" statistics.

Medicare Outpatient Observation Notice

Mary Beth Pace, RN, BSN, MBA, ACM, CMAC

Mary Beth Pace is vice president of care management at Trinity Health.

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