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April 2010
UTILIZATION REVIEWHOW 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
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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 Bedshttp://www.mtrules.org/gateway/Subchapterhome.asp?scn=37%2E40%2E4
Montana Medicaidhttp://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 Acthttp://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
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