I recently took part in a very distressing call that raised a significant ethical and compliance dilemma for a physician. I occasionally get contacted confidentially with issues such as this, and as such I will reveal no specific details of this person’s identity or facility in order to protect them. The caller is a part-time physician advisor for a community hospital with a teaching program who also performs second-level review for level of care and medical staff outreach and education.

The doctor is also very diligent and understands medical necessity in general and for hospitalization, and he has a thorough understanding of the two-midnight rule.

Since the two-midnight rule went into effect, this physician’s hospital has seen a drop in the number of inpatient admissions and an accompanying drop in revenue. And as in many states, the Medicaid program has also cut reimbursements to hospitals. As can be expected, the chief financial and chief executive officers are not happy with the drop in revenue and have made it clear that it is not acceptable.

This result of this is that pressure is being placed on the case management department and this physician advisor to admit more Medicare patients as inpatients. The CEO and CFO have stated that the Recovery Auditors (RAs) are not auditing records, and since the quality improvement organization (QIO) is only going to audit 10 charts every six months, they perceive that the risk created by being generous with admission decisions is low.

As in many hospitals, this doctor often sees patients staying past a second midnight but without medical necessity; in one such instance, for example, an EEG was done but the neurologist was not around in the afternoon to read it, so the patient stayed another day. A patient with a negative syncope workup was kept another day because he has not suffered any arrhythmia yet, and according to the doctor, 24 hours is not enough. And administration wants the physician advisor to approve these as inpatient as well.

The C-suite also wants the hospital to push the boundaries on the new exception for one-midnight stays, using physician judgment that inpatient is warranted, but that exception requires the physician to document rationale – and this physician advisor knows the doctors have a hard time documenting justification for hospital care at all. He cannot see them changing their documentation to the point that it would support a one-midnight inpatient admission.

This doctor had already talked to the compliance officer, but sensed that he was also getting pressure from the C-suite. Of course, there is no memo from the C-suite telling doctors to admit more patients, so it is really just hearsay.

So, what should be this doctor’s next step? Loyal RACmonitor readers, I want your suggestions. What would you do if that was your mandate from your C-suite and it was supported by the compliance officer?

Drop me an email at rhirsch@accretivehealth.com or use the contact box on my website, www.ronaldhirsch.com, and use an alias.  

I’ll present your suggestions, anonymously of course, on a future Monday Rounds and in a future RACmonitor article.

About the Author

Ronald Hirsch, MD, FACP, CHCQM, is vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. 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 he is a published author on the topic. He is a member of the Advisory Board of the American Case Management Association and a Fellow of the American College of Physicians.

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Please join RACmonitor and Dr. Hirsch today for our webcast Revenue from Surgery: Learn How to Optimize Revenue Integrity Compliantly. Your revenue from surgery be at risk. Risk-prone factors surrounding surgical procedures conducted at your facility could pose serious compliance issues. Dr. Hirsch explains today at 1:30 PM ET. Register here.

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