Issues Arise When They Can’t Live at Home

One of the most frustrating situations faced by physicians and case managers is the patient who can no longer live independently. Most of these patients got to that point in their lives over a prolonged period of decline, and they either refuse to admit that they need help until it is too late, or their family tries its best, but never thought to make contingency plans.

Unsurprisingly, most of these people turn to the hospital at this time of crisis. And the help they expect is that the patient will be admitted as an inpatient and kept for at least three days so they qualify to be transferred to a nursing home and have Medicare pick up the tab.

I’ll admit that I did exactly that several times in the distant past, because back then everyone did it and no one questioned it. And as I think back, I don’t think I ever really knew the rules; we knew three days were needed, but that’s all. But that was then and this is now. So why can’t we just admit these patients and keep them three days? Well, there are actually four hurdles that must be overcome.

Hurdle No. 1: Necessity for Hospital Care

First, the patient must require hospitalization. Medicare says, “the crux of the medical decision is the choice to keep the beneficiary at the hospital in order to receive services or reduce risk, or discharge the beneficiary home because they may be safely treated through intermittent outpatient visits or some other care.” Patients who are unable to live at home in general do not require hospital care at all; they would be perfectly safe at home if they had someone to take care of them or they could go directly to a nursing home, where there is staff to care for them.

Hurdle No. 2: Inpatient Admission

If we do hospitalize the patient, the next hurdle is that in order to admit them as an inpatient, there must be an expectation that they will require at least two midnights of necessary hospital care. Perhaps we can justify one midnight to look for infection or a metabolic derangement that is causing their decline, but typically, not two or more midnights. That’s the new reality that we have all faced since Oct. 1, 2013, and the new exception for physician judgment certainly does not apply here.

Hurdle No. 3: A Three-Day Stay

But let’s say we do think they will need two midnights and warrant inpatient admission. That is still not enough, because to qualify for Part A payment of their nursing home stay, they must have an inpatient admission of three or more consecutive days – and that is unlikely. The Medicare Benefit Policy Manual says that a three-or-more-day admission would not qualify for coverage only if it is a substantial departure from normal medical practice, and keeping a patient for three days to get qualification for a paid nursing-home stay would certainly represent such a departure. In fact, Medicare reports three-day inpatient admissions that lead to a nursing home stay on the Program for Evaluating Payment Patterns Electronic Report (PEPPER) as an error-prone area.

Hurdle No. 4: Skilled Needs

But even if the patient does stay three days and goes to a nursing home, Part A coverage is only available if the patient has skilled needs. And the reality is that most of these patients have purely custodial needs. When a patient is admitted to a nursing home, the staff completes the minimum data set, the results of which assign the patient to one of five resource utilization group (RUG) categories. If a patient falls into one of the higher RUG categories, it is clear they require skilled care. But that is not true for those patients who fall into the lowest RUG category. In fact, in a 2016 report, Palmetto noted that 60 percent of patients in the lower-level RUGs did not have skilled needs. How many nursing homes will be willing to accept a patient knowing there is a 60 percent chance they won’t get paid?

What is the solution? I wish I knew. As I noted, these patients rarely have a sudden deterioration, but rather there is one more straw that breaks the camel’s back. But patients and families never know to start planning ahead when the basket is half-full of straws. There are organizations such as senior services that can help; perhaps they need to conduct more outreach to primary care physicians to increase awareness and start planning earlier in the process. Perhaps these organizations need to develop SWAT-like teams to respond when a patient needs immediate assistance, either at home or at the hospital.

But I do know that as much as we want to help patients, we cannot admit all of them as inpatients. We will find and offer the available resources, provide options to patients and their families, and often keep the patient for days to weeks to obtain Medicaid coverage or guardianship. It’s just one of those obligations to our communities that we would rather not have to face – but until there is a better solution, we will continue to face it with compassion and dignity, yet not with gaming the system.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. 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 is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, and the National Association of Healthcare Revenue Integrity, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

Related Stories

The “Car Guy” Who Became a “Doc”

The Death of an Actor

EDITOR’S NOTE: In recognition of National Doctors’ Day, coming up at the end of the month, starting Monday, March 25, MedLearn Media will be honoring

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

HIM coding expert, Kay Piper, RHIA, CDIP, CCS, reviews the guidance and updates coders and CDIs on important information in each of the AHA’s 2024 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 15, 2024

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

SPRING INTO SAVINGS! Get 21% OFF during our exclusive two-day sale starting 3/21/2024. Use SPRING24 at checkout to claim this offer. Click here to learn more →