QIOs Urged to Stop Denials for Lack of Timely Authentication

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Original story posted on: August 29, 2018

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I have whined in a previous RACmonitor enews article about how the importance given to the admission order in today’s healthcare industry makes absolutely no sense. It’s not an order for a medication or a test, wherein if it is transcribed incorrectly, the patient could be physically harmed. The admission order is different. It is for payment, and simply a way to determine if hospital care will be paid by DRG or APC.

So, why the fuss? Because the Centers for Medicare & Medicaid Services (CMS) says so. And when CMS says something, we must listen.

When in 2013, as part of the 2014 Inpatient Prospective Payment System (IPPS) rule sub-regulatory guidance, the agency said the admission order needs authentication prior to discharge, we listened. And many hospitals self-denied admissions because of the lack of that authentication – perfectly good admissions with no revenue because of the absence of one click by a physician.

And when the Medicare Administrative Contractors (MACs) and Quality Improvement Organizations (QIOs) started the two-midnight probe-and-educate audits, that was the first thing they did: they looked for the admission order, then the date and time of the authentication of that order.

No authentication prior to discharge meant an automatic technical denial, with no way to appeal. So for four years, inpatient admissions that complied with all the other regulations were denied simply because of the authentication.

But as you know, CMS has fixed that, as of Oct. 1. Authentication prior to discharge will no longer be a requirement.

Now, why did CMS change the rule? Well, as CMS itself said, “when we finalized the admission order documentation requirements in past rulemaking and guidance, it was not our intent that admission order documentation requirements should, by themselves, lead to the denial of payment for medically reasonable and necessary inpatient stay.”

Unfortunately, they did not tell that to the MACs or the QIOs. In fact, the QIOs are in regular contact with CMS, discussing their audit results, so that means CMS had to have known there were many of these denials.

Which leads me to the point of this article. While we wait for Oct. 1 to arrive, the QIOs continue to audit short stays and deny for lack of timely authentication. There is no reason for them to wait until Oct. 1; they should stop these denials immediately. When CMS states that it was never their intent, that means that for the last four years, even though the manual and their guidance stated it was a requirement, in CMS’s eyes, these denials should not have occurred.

So if they are admitting now that the MACs and QIOs misinterpreted their intent, why would we need to wait another two months for these denials to stop?

I don’t expect a reversal of all such denials over the last four years, but I think the least the QIOs could do would be to stop enforcing it now. Right now, the QIOs have the discretion to approve admissions with the complete absence of an admission order. It would seem reasonable that the QIOs can use this discretion to approve admissions for which the authentication is untimely.

Hospitals with pending denials that are awaiting their educational calls should discuss this with the QIO during the calls and ask them to read CMS’s words, use their discretion, and consider overturning the denials.

 

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Ronald Hirsch, MD, FACP, CHCQM

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays.

The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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