Holiday Schedule 

The ABQAURP office will be closed the week of December 26th. We will reopen on Monday, January 2nd. All calls and emails will be returned at the first of the year. Happy Holidays!

Diplomate Focus 

The Anatomy of a Review: Seven Points to Consider Regardless of Payor or Provider Viewpoint
By Hemant Gupta, MD, MSc, CHCQM-PHYADV

You are a physician advisor, or a health plan medical director, and you have been sent a case from a UR nurse who is asking you for your professional opinion on a medical necessity review for a level of care. 

Your choices are to keep the status observation, downgrade to outpatient in a bed, or upgrade it to inpatient. Here are some points to consider: 
1. Consider the insurance plan of the patient. Yes, when making status determinations it is important to discern if the case is for Medicare fee-for-service (FFS) vs non-Medicare FFS. 

2. Consider the attending’s concerns in the documentation and the status they chose and why they chose it. Did the care that was documented seem reasonable and necessary by the practice standards of that hospital, region,  and did it span for two midnights (especially for Medicare FFS)? 

3. How long has the patient been in the hospital? Are they a transfer? When did the episode of care start? (Be aware of the two-midnight clock start in a Medicare FFS case.) 

4. Do not get married into a diagnosis and equate it to a specific status. Have an open mind. Review all the relevant primary information, when possible, prior to making a decision. 

5. Consider using MCG and InterQual guidelines in helping you come to the decision, especially if 48 hours or so have elapsed and the patient still needs hospital level services. Be aware, Medicare FFS does NOT ascribe to commercial criteria for Medicare FFS cases at the secondary review level.

6. What is present at the time of your review and what is NOT present at the time of your review is equally important. 

7. If unsure of status, and it is possible to call the attending, please do! You may be surprised by what you learn. There is a lot that does NOT get documented in the record that is indeed quite important. This is an opportunity to make a relationship and extend gratitude for the hard work of clinical care. Be careful to not guide, direct their care, or give them the idea that it is not medically necessary. It is very important to stay constructive, positive, and leave the door open even if you disagree.

Remember, you are doing a clinical review of a case for a financial payment of care. You are not the attending. Writing a review has several parts. The clinical summary, the diagnosis, and the rationale under which you made your determination are parts of a strong review. 

Painting an accurate picture, utilizing evidence-based medicine guidelines, risk calculators, commercial criteria, the two-midnight rule or its exceptions, and discussing a case for a specific status and against a status are all tips to help improve your argument. 

Try not to repeat the clinical summary in your rationale. Try not to be generic in your statements or create canned text. None of these strengthen your review. If a statement can be used in every case, then it lacks specificity of “why” this patient, “why” now, and “why” this status. 

We are put into a unique situation in these case reviews. No two people are alike, neither are their care pathways or stories. Be specific, it will show you reviewed all the relevant data and made the BEST decision with that data at hand. An audit can come from the state, the federal government, a QIO, RAC/MAC, IRO, an appeals committee, the system level, a hospital, or a courtroom. Make your reviews count, make them legible and professionally written. Time taken early will save time later when you wonder what you were thinking when you recommended a status. Strong reviews are internally consistent and show the use of many angles for a case for a specific status. You will never please all sides. Stick to the medical record, case discussions with the attending, social, safety, standards of care, psych/behavioral, and need for care or for a lack of the need. Remember, medically necessary care is care that is needed and not merely existent, without which the patient would suffer with a poor outcome. 

If the above is new, or you are struggling with these, remember there is training for this kind of thing. You are not alone! 

References:
Federal Register/August 19, 2013/Summary: https://www.federalregister.gov/documents/2013/08/19/2013-18956/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the

CMS Fact Sheet: Two-Midnight Rule: https://www.cms.gov/newsroom/fact-sheets/fact-sheet-two-midnight-rule-0

Livanta QIO: https://www.livantaqio.com/

CMS Oversight of the Two-Midnight Rule for Inpatient Admissions summary: https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000538.asp

RACmonitor “The Nuances of the Two-Midnight Rule”: https://racmonitor.medlearn.com/the-nuances-of-the-two-midnight-rule/

Federal Register/Vol 80, No 219/Friday, November 13, 2015/Rules and Regulations: https://www.govinfo.gov/content/pkg/FR-2015-11-13/pdf/2015-27943.pdf