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UTILIZATION REVIEW. HOW TO GET PAID (CORRECTLY) FOR PROVIDING CARE AND SERVICE. OVERVIEW. UR Plan Tasks Patient Status Patient Rights Notices Tools References. PLAN. Committee Scope and frequency of review Staffing Criteria Determinations regarding admissions or continued stays
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UTILIZATION REVIEW HOW TO GET PAID (CORRECTLY) FOR PROVIDING CARE AND SERVICE April 2010
OVERVIEW • UR Plan • Tasks • Patient Status • Patient Rights • Notices • Tools • References April 2010
PLAN • Committee • Scope and frequency of review • Staffing • Criteria • Determinations regarding admissions or continued stays • Extended stay review • Performance improvement April 2010
TASKS • Observation • Payer source • UR line • Criteria • Length of stay • Quality • CMS measures • Present on admission • Hospital-acquired infections April 2010
OBSERVATION • Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. • Postop amb surg: 4-6 hours of recovery, unplanned outcome or exacerbation of a condition; other wise extended recovery April 2010
INPATIENT • The physician is responsible for deciding whether the patient should be admitted as an inpatient; should use a 24-hour period as a benchmark; requires complex medical judgment and consideration of a number of factors • Severity of illness and intensity of service • Benefit period: 60F + 30C > 60O (+ 60L) April 2010
SWING BED • 3 day qualifying stay • 30 day window • Benefit period: 20F +80C > 60O • Physician certification on admission • Recertification day 14, day 44, day 74 • Related condition, daily skilled need, inpatient setting, reasonable & necessary April 2010
SWING BED – examples of skilled services • Nursing • Management & evaluation of a patient care plan – require the involvement of skilled personnel to meet patient needs • Observation & assessment of patient’s condition – when there is a likelihood of change in patient condition • Teaching & training activities – injections, new diabetic, care of dressings or skin treatments, care for central lines, self-catheterization, colostomy care, gastrostomy feedings, prosthesis care • Direct skilled nursing – IV therapy, Stage 3 or > pressure ulcer treatments, dressings involving aseptic technique • Therapy • Based on eval by qualified PT; require judgment, knowledge, skills of PT; potential for patient improvement over reasonable period of time; specific & effective for patient condition; reasonable & necessary amount, frequency, & duration • Examples: Assessment, therapeutic exercises, gait training, range of motion, maintenance therapy, Ultrasound, shortwave, and microwave diathermy treatments, Hot packs, Infra-Red Treatments, Paraffin Baths, and Whirlpool Baths, Speech-Language Pathology, Occupational Therapy April 2010
SWING BED – Medicaid • If MA is primary or secondary, prior authorization is required • Must transfer to NH unless no skilled NH bed available within 25 miles OR physician may request waiver in writing if: • Transfer would endanger patient OR • Life expectancy is 6 months or less • Level of Care & Level I forms to MPQH • Waiver request to Senior & LTC Division April 2010
MEDICAID – Mental Health • Verify MA eligibility (Mental Health Access Program does not cover – 72 hr presumptive eligibility program available if no pay source) • Notify First Health Services (https://montana.fhsc.com) – prior authorization request form within 1 business day • Under age 21: Certificate of Need within 14 days • Discharge form within 5 business days after discharge April 2010
MEDICAID – Alcohol & Drug Detox • Limited to 4 days unless necessary adjunct to treatment of a concomitant condition • Obtain authorization by contacting DPHHS RN Case Manager April 2010
COMMERCIAL PAYERS • “Swing Bed” rates can be negotiated with some commercial payers • Patient’s policy needs to cover skilled care services • No prior authorization is required in connection with childbirth for a mother and her newborn; 48 hour postpartum vaginal delivery; 96 hour postpartum c-section April 2010
INPATIENT HOSPICE • Respite Care - short-term inpatient care to relieve caregivers at home - only on an occasional basis - no more than 5 consecutive days at a time • General Inpatient Care – may be required for procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings April 2010
CHANGING PATIENT STATUS • IP to Observation • Medicare: prior to discharge, no claim submitted, physician concurs, concurrence is documented • Can only bill from the time the observation orders are written (condition code 44) • Must notify patient • Commercial: variance order • Observation to IP • Precertification required for commercial IP stay April 2010
MEDICARE DISCHARGE APPEAL RIGHTS • “Important Message from Medicare” • Within 2 days of admission AND discharge • Signed original to patient, copy to record • May use same notice for initials at discharge • “Detailed Notice of Discharge” • Deliver to patient no later than noon of the day after the QIO notification to the hospital April 2010
MEDICARE NOTICES • OBSERVATION • When otherwise covered services will be noncovered • If services will no longer be reasonable or necessary • ABN (Advanced Beneficiary Notice) given prior to service April 2010
MEDICARE NOTICES • INPATIENT • Given when care not medically necessary, not delivered in the most appropriate setting, or is custodial in nature • HINN 1 (preadmission/ admission) • HINN 10 (Hospital Requested Review – HRR) without physician concurrence • HINN 11 (non-covered items or services during an otherwise covered stay) • HINN 12 (non-covered continued stay) April 2010
MEDICARE NOTICES • SWING BED • “Notice of Medicare Provider Non-Coverage” – at least 2 days prior to discharge • “Detailed Explanation of Non-Coverage” – when QIO review is requested • Notice of Exclusions from Medicare Benefits (no qualifying 3 day hospital stay, no days left in benefit period, daily skilled care requirements not met) – HINN or NEMB? April 2010
DOCUMENTATION - provider • Physician: take care of patients and document well • Documentation requirements: • OP Treatment: Dx, Tx • OP Procedure: if pt not ready after 6 hrs routine recovery, order extended recovery or Observation (or IP) • Observation: Reason for observation, tests, txs, monitoring parameters, decision point (intervene -> assess -> discharge or IP or intervene -> etc) • IP: severity of illness, intensity of service • SB: response to skilled care • Hospice Acute: pain and symptom control April 2010
DOCUMENTATION - nurse • Nurse: take care of patients and document well • Documentation requirements: • OP Treatment: patient care and responses • OP Procedure: if pt not ready after 6 hrs routine recovery, get order for extended recovery or Observation (or IP) • Observation: tests, txs, patient response, communication with physician • IP: severity of illness, intensity of service • SB: response to skilled care • Hospice Acute: pain and symptom control April 2010
REFERENCES • 42CFR § 482.30 Medicare Conditions of Participation Standards for Hospital Utilization Review http://edocket.access.gpo.gov/cfr_2004/octqtr/pdf/42cfr482.30.pdf • Medicare Benefit Policy Manual, Chapter 1 - Inpatient Hospital Services Covered Under Part A http://www.cms.hhs.gov/manuals/Downloads/bp102c01.pdf • Medicare General Information, Eligibility, and Entitlement, Chapter 4 - Physician Certification and Recertification of Services http://www.cms.hhs.gov/manuals/downloads/ge101c04.pdf April 2010
REFERENCES • Medicare Benefit Policy Manual, Chapter 6 - Hospital Services Covered Under Part B http://www.cms.hhs.gov/manuals/Downloads/bp102c06.pdf • Medicare Benefit Policy Manual, Chapter 3 - Duration of Covered Inpatient Services http://www.cms.hhs.gov/manuals/Downloads/bp102c03.pdf • Medicare Benefit Policy Manual, Chapter 8 - Coverage of Extended Care (SNF/SB) Services Under Hospital Insurance http://www.cms.hhs.gov/manuals/Downloads/bp102c08.pdf April 2010
REFERENCES • Medicare General Information, Eligibility, and Entitlement, Chapter 3 - Deductibles, Coinsurance Amounts, and Payment Limitations http://www.cms.hhs.gov/manuals/downloads/ge101c03.pdf • ARMs 37.40.4 Swing Beds http://www.mtrules.org/gateway/Subchapterhome.asp?scn=37%2E40%2E4 • Montana Medicaid http://www.dphhs.mt.gov/programsservices/medicaid.shtml April 2010
REFERENCES • ARMs 37.88.11 : Medicaid Mental Health Services: Inpatient Psychiatric Services http://www.mtrules.org/gateway/ChapterHome.asp?Chapter=37%2E88 • ARMs 37.86.29 Medicaid Primary Care Services: Inpatient Hospital Services http://www.mtrules.org/gateway/Subchapterhome.asp?scn=37%2E86.29 • FHSC Montana Adult Acute Inpatient Provider Manual, Version 2.1, December 1, 2008 https://montana.fhsc.com/Downloads/Adult/manuals/MT_A_Acute_ProviderManual_2_1-20090506.pdf April 2010
REFERENCES • Newborns’ and Mothers’ Health Protection Act http://www.dol.gov/federalregister/HtmlDisplay.aspx?DocId=21637&AgencyId=8 • Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance http://www.cms.hhs.gov/manuals/Downloads/bp102c09.pdf • Medicare Claims Processing Manual, Chapter 30 - Financial Liability Protections http://www.cms.hhs.gov/manuals/downloads/clm104c30.pdf April 2010
REFERENCES • CMS Home > Medicare > Beneficiary Notices Initiative (BNI) > Hospital Discharge Appeal Notices http://www.cms.hhs.gov/BNI/12_HospitalDischargeAppealNotices.asp#TopOfPage • CMS Home > Medicare > Beneficiary Notices Initiative (BNI) > Overview http://www.cms.hhs.gov/bni/ • CMS Home > Medicare > Beneficiary Notices Initiative (BNI) > FFS Revised ABN http://www.cms.hhs.gov/BNI/02_ABN.asp#TopOfPage April 2010
REFERENCES • CMS Home > Medicare > Beneficiary Notices Initiative (BNI) > FFS HINNs http://www.cms.hhs.gov/BNI/05_HINNs.asp • CMS Home > Medicare > Beneficiary Notices Initiative (BNI) > FFS ED Notices http://www.cms.hhs.gov/BNI/06_FFSEDNotices.asp#TopOfPage • CMS Home > Medicare > Beneficiary Notices Initiative (BNI) > FFS NEMB SNF http://www.cms.gov/BNI/13_FFS%20NEMB%20SNF.asp#TopOfPage April 2010
