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Value of Case Management:
(CMS Tools- Across the Continuum)
Connecticut Chapter: ACMA
October 26, 2013
Faculty
Jackie Birmingham, RN, BSN, MS, CMAC
VP, Emerita, Curaspan Health Group
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Agenda
• Introduction –
• CMS Tools – Conditions of Participation
•
COPs: Utilization Review & Discharge Planning
•
FY2014 IPPS : time-based (24-48) hour admission &
transition
• What hasn’t changed and what has changed
• A peak at Hospital Value Based Purchasing – 2014-2015
• Summary of key takeaways
• Q&A
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Introduction
• Terms for ‘across the continuum’
• Transition of Care, Case Management, Care Coordination
• Discharge Planning and Utilization Review
• Case Management is not an isolated function process:
• It is an essential broad-based concept involving clinical process of
care
• It involves transition in-out-through multiple of levels of care
• Core Values
• Patient safety and improve outcomes
• Efficiency (appropriateness)
• Financial Stability
• Compliance
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The big shift - Incentives
Shifting Incentives
• incentives from ‘quantity’ to ‘quality
• to more ‘patient involvement’
• to preventive care
• to coverage of ‘comprehensive’ health care
services for all
• Still following the
payment/practice/payment cycle
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An evolution perspective
• 1965: 50 years – SSA (Part A, Part B, SNF Benefit)
• 1972: 40 years - Utilization Review Standards
• Admission, continued stay, professional services
• 1983: 30 years Prospective Payment (PPS- DRGs)
• Bundled payment, Outpatient observation
• 1988: 25 years: Discharge Planning Standards
• Identify, assess, plan, implement , discharge,
• 2010: 3 years: The Affordable Care Act
• 2013/4: Time-based presumption of
admission
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Practice - Payment - Cycle
Practice
Payment
Audit
Outcomes
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E.g.: Practice-Payment-Cycle
“Observation Services”
• 1983: New Payment method - PPS/DRG:
• Admit – get paid DRG
• Audits of appropriateness of admission
• Please – we can’t admit or discharge
• What can we do?
• How about keeping patient as outpatient?
• ‘Observe’ for 24 hours?
• Sounds good
• Let’s do it!
• But – who knew?
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Admission decision challenge
• OIG-OEI Report: July 2013
• “On Average, Medicare Paid Nearly Three Times More for a
Short Inpatient Stay Than an Observation Stay and
Beneficiaries Paid Almost Two Times More.”
• Assigning admission level of care (outpatient or
inpatient)
• direct impact on what the patient pays and how it
impacts the patients use of post-acute extended
care services (SNF).
• Hospitals inconsistent practices made it necessary
for CMS to do something
• level the playing field for paying for services.
• My opinion – the time-based rule has merit
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Medicare payment for short stays
• In total, Medicare paid $5.9 billion for short inpatient stays,
• an average of $5,142 per stay.
• In contrast, it paid $2.6 billion for observation stays, an average of
$1,741 per stay.
 Note: Hospitals used inconsistent admission
practices
 Some hospitals were more likely to use short
inpatient stays,
 Others were more likely to use observation or
long outpatient stays.
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What hasn’t changed….
• The Federal Rules (Social Security Act)
• rules & regulations for hospitals
• The Conditions of Participation
• Utilization Review
• Discharge Planning
• The Interpretive Guidelines (IG) (revised)
• What Surveyors look for is ‘rearranged’
• More focus on ‘transition’
• Pilot Process:
• Advisory – Blue Boxes
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Utilization Review • Existing Standards:
• Admission review
• Continued stay review
• Professional Services
• Does the patient meet medical necessity for admission?
• If yes, which level?
• If no, what are the options?
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3 Reasons to watch admissions
1. EMTALA (Emergency Medical Treatment and Active Labor
Act) – still in force – still causing problems (Anti-dumping
law)
• Determining if the ED patient meets admission criteria is necessary.
• Hospitals still being monitored for EMTALA violations
2.
DSH (Disproportionate Share Hospital) DSH status.
• DSH Hospitals will be getting less money assuming that more
patients will have some type of coverage.
• What information can you collect at admission that will support the
status of an unfunded treatment plan for individuals.
3. The time-based rule changes for hospitals,
• ‘presumption ‘ of inpatient admission to Medicare Part A services
after 48 hours
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5 Reasons to watch the clock
SNF- CB
3 Midnight
Rule
Part A after 48
hours
Readmission
Rates
Midnight not
the time to
Discharge
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UR: Time-Based Admission review
• Review of medical necessity
• Predict: severity, intensity and how long the
patient is expected to be inpatient!
• New ‘approach’ for Inpatient Status
• Predict the need for admission
• Clinical criteria, services only available as
inpatient
• Inpatient only list
• The 1-2- ‘midnights’: “Presumption”
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The 2-midnight presumption
• The 2-midnight presumption directs medical reviewers to
select claims for review
• under a presumption that the occurrence of 2 midnights after
formal inpatient hospital admission signifies an appropriate
inpatient status for a medically necessary claim.
• CMS will instruct the Medicare Administrative
Contractors (MACs) and Recovery Auditors
• that they are not to review claims spanning more than two
midnights after admission for a determination of whether the
inpatient hospital admission and patient status was appropriate.
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Default method:
Admission order and Certification
•Reasonable & Necessary
•Inpatient only
•Or explain why inpatient
needed
•Requirement met by
either physician notes or
by discharge planning
instructions
•inpatient treatment or
medically required
inpatient diagnostic
study
a.
Authentication
of the Order
b. Reason for
the inpatient
service
d.
Posthospital
care plan
c. Estimated
time for
inpatient
• How long [ n hours]
needed for inpatient
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Hospital Inpatient Admission order
and Certification (9-5-2013)
a. Authentication of the practitioner order:
This includes certification that hospital inpatient services are
reasonable and necessary and in the case of services not specified
as inpatient‐only under 42 CFR 419.22(n), that they are
appropriately provided as inpatient services in accordance with the
2‐midnight benchmark under 42 CFR 412.3(e).
b. Reason for inpatient services: The reasons for either— (i)
Hospitalization of the patient for inpatient medical treatment or
medically required inpatient diagnostic study; or (ii) Special or
unusual services for cost outlier cases under the inpatient
prospective payment system (IPPS);
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Estimate LOS and plan for discharge
c. The estimated time the beneficiary requires or
required in the hospital.
•
•
•
•
Estimate in hours?
How?
Tests needed (is radiology available)?
If using outside reviewers – how long will that
take?
• Ask for Physician Advisor opinion?
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“Plans for Posthospital care”
d. The plans for posthospital care, if appropriate, and
as provided in 42 CFR 424.13.
42 CFR Ch. IV (10–1–11 Edition)
• (b) Certification of need for hospitalization when a SNF
bed is not available.
• (1) A physician may certify or recertify need for continued
hospitalization if the physician finds that the patient could receive
proper treatment in a SNF but no bed is available in a participating
SNF.
• (2) If this is the basis for the physician’s certification or recertification,
the required statement must so indicate;
• and the physician is expected to continue efforts to place
the patient in a participating SNF as soon as a bed
becomes available.
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What to document for SNF Level?
• Review the MDS (Minimum Data Set)
• What terms do they use
• RUG-III classification based on the information
from the Medical Necessity and Level of Care
(MN and LOC) assessment.
• What type of therapy? PT, OT, ST
• How much? Why?
• Need for 24/7 nursing supervision
• Why not at home (amount of therapy,
comorbidities, ADLs)
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A word about 3 midnights for SNF
• 3 midnight – SNF (Skilled Nursing Facility) Extended
Care Benefit
• Patient must still have 3 ‘inpatient’ midnights
• Observation status – doesn’t count
• Admit to inpatient can count starting at the time of
‘inpatient’ stay order
• Part A payment not necessary for SNF benefit
• Medical necessity for SNF benefit is KEY
• Improving Access to Medicare Coverage Act of 2013
(H.R. 1179) – Pending Legislation
• Law suit – 9/23/2013 – stays the same –
• Observation not inpatient
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Hospital: 3+ days but no SNF
 617,702 beneficiaries
 had hospital stays lasting more than 3 nights (or
more)
 but did not qualify for SNF extended care
coverage
 4% (25,245) received SNF services for which they
did not qualify
• Medicare inappropriately paid $255 million for
these services
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Advice from Surveyors (IGs)
• CMS : Center for Clinical Standards and
Quality/Survey & Certification Group
• May 18, 2013 Ref: S&C: 13-32- HOSPITAL
• Surveyors’ Worksheets: update IGs
• Advisory Boxes (Blue Boxes): updated
interpretive guidelines share practices used to
promote better patient outcomes.
• Information in advisory boxes is not required for
hospital compliance
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Discharge Planning ‘Advisory Boxes’
• Do discharge planning for ‘outpatients’ (observation)
• Develop discharge policies with input from:
• Medical staff & facilities that provide after-care
• If patient refuses discharge planning – document
• The discharge plan does not stop at discharge
•
•
•
•
Schedule follow-up appointments
Filling prescriptions prior to discharge
Arrange remote monitoring technologies
Follow-up phone calls
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Discharge Planning ‘Advisory Boxes’
for Surveyors
CMS - Center for Clinical Standards and Quality/Survey &
Certification Group –
Pilot project prior to revisions of IG
• Do discharge planning for ‘outpatients’ (observation)
• Develop discharge policies with input from:
• medical staff
• Other facilities that provide care after discharge
• If patient refuses discharge planning – document
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IG: Actions expected by Surveyors
• All patients will be screened for discharge needs
• How do you screen those outside the criteria
• Assessment will be based on the patients preadmission level of care
• Staff doing ‘discharge planning’ must be
qualified
• Patient choice – patient preference – no
obligation to develop a discharge plan that
cannot be implemented
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Impact of VBP Domains on CM
1. Clinical processes of care: Take care of patient’s
medical needs while planning for discharge
2. Patient Experience of Care: score after discharge
3. Outcomes: right next level of care – Hospice
4. Efficiency – (Part A and Part B) How much did
Medicare pay for 3 days before admission- the
admission - and 30 days after discharge?
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Key points – value
• Know your patients need you to be Case Managers –
• Assessment the patient/family
• Know levels of care – which one, when, why, expectations
• Know your organization needs Case Managers to stay in
business!
• coders, physicians, CXOs
• Know that you are the experts in management ‘across the
levels of care’
• Nobody else is
• No program or process can succeed without Case Management
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Thank you.
Contact information:
Jackie Birmingham, RN, BSN, MS, CMAC
[email protected]
Or
[email protected]
Phone: (860)519-4499
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