a) The patient underwent bilateral knee or bilateral hip joint replacement surgery during the acute hospital admission immediately preceding the
IRF admission.
b) The patient is extremely obese with a Body Mass Index of at least 50 at
the time of admission to the IRF.
c) The patient is age 85 or older at the time of admission to the IRF.
In addition to one of the above diagnoses, patients should also require rehabilitative services in an inpatient hospital rather than a less intensive setting such as a SNF, or on an outpatient basis or with home health care. A multi-disciplinary team approach, consisting of the physician, therapists, nurses, care management, pharmacy, and when necessary, respiratory, are needed to help manage the patients care.
Patients admitted to an IRF are expected to be able to make significant functional improvement in a short period of time (typically 10-14 days) and be able to transition to their home environment or another community based setting (i.e. assisted living), rather than an institutional setting (i.e. SNF) at the end of this period.
Finally, patients admitted to an IRF have the need for not only 24/7 rehabilitation nursing but 24/7 access to a physician specially trained in rehabilitative medicine.
For more information on Inpatient Rehabilitation Facilities, please access this article from CMS - click here.
Is Part B billing allowed when an inpatient admission was not appropriate?
July 23, 2014
The Since You Asked Committee was asked if Part B billing was allowed when an inpatient admission was not appropriate. Listed in an MLM Bulletin, Part B Services are billable under the following circumstances. The link to the Bulletin will be added at the end of the article. It can also be found under the Medicare Document 1599-F in the Medicare Benefit Payment Manual.
Medicare Part B is allowable as a payment option in the following conditions:
When Medicare Part A payment cannot be made because an inpatient admission is found to be not reasonable and necessary and the beneficiary should have been treated as a hospital outpatient rather than a hospital inpatient, Medicare will allow payment under Part B of all hospital services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient, rather than admitted to the hospital as an inpatient, except for those services that specifically require an outpatient status, such as outpatient visits, emergency department visits, and observation services, that are, by definition, provided to hospital outpatients and not inpatients. Part B payment may only be made if the beneficiary is enrolled in Part B, the allowed timeframe for submitting claims is not expired, and waiver of liability payment is not made.
This policy applies when a hospital determines under Medicare's utilization review requirements that a beneficiary should have received hospital outpatient rather than hospital inpatient services, and the beneficiary has already been discharged from the hospital (commonly referred to as hospital self-audit).
- If the hospital already submitted a claim to Medicare for payment under Part A, the hospital must cancel its Part A claim prior to submitting a claim for payment of Part B services.
- Whether or not the hospital has submitted a claim to Part A for payment, Medicare requires the hospital to submit a “no pay” Part A claim indicating that the provider is liable under section 1879 of the Act for the cost of the Part A services.
- The hospital may then submit an inpatient claim for payment under Part B for all services that would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient rather than admitted as a hospital inpatient, except where those services specifically require an outpatient status.
Services Billable under Part B
Beginning in 2014, for hospitals paid under the OPPS these Part B inpatient services are separately payable under Part B, and are excluded from OPPS packaging if the primary service with which the service would otherwise be bundled is not a payable Part B inpatient service.
The following inpatient services are payable under the OPPS:
- Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests;
- X-ray, radium, and radioactive isotope therapy, including materials and services of technicians;
- Acute dialysis of a hospital inpatient with or without End Stage Renal Disease. The charge for hemodialysis is a charge for the use of a prosthetic device, billed in accordance with Pub. 100-04, Medicare Claims Processing Manual chapter 4, section 200.2, “Hospital Dialysis Services for Patients With and Without End Stage Renal Disease (ESRD).”
- Screening pap smears;
- Influenza, pneumococcal pneumonia, and hepatitis B vaccines;
- Colorectal screening;
- Bone mass measurements;
- Prostate screening;
- Hemophilia clotting factors for hemophilia patients competent to use these factors without supervision;
- Immunosuppressive drugs;
- Oral anti-cancer drugs;
- Oral drug prescribed for use as an acute anti-emetic used as part of an anti-cancer chemotherapeutic regimen; and - Epoetin Alfa (EPO) that is not covered under the End-Stage Renal Disease benefit.
The following inpatient services are payable under the non-OPPS Part B fee schedules or prospectively determined rates listed:
- Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations (DMEPOS fee schedule);
- Prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of such devices and including one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of intraocular lens (DMEPOS fee schedule, except for implantable prosthetic devices paid at the applicable rate under the Medicare Claims Processing Manual Chapter 4 section 240.3, “Inpatient Part B Hospital Services - Implantable Prosthetic Devices”);
- Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes including replacements if required because of a change in the patient’s physical condition (DMEPOS fee schedule);
- Physical therapy services, speech-language pathology services, and occupational therapy services (see chapter 15 sections 220 and 230 of the "Medicare Benefit Policy Manual", “Covered Medical and Other Health Services”) (applicable rate based on the Medicare Physician Fee Schedule);
- Ambulance services (ambulance fee schedule); and
- Screening mammography services (Medicare Physician Fee Schedule).
To find the bulletin, please follow this link: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R182BP.pdf
Can inpatient admission orders be made retroactively according to the Medicare FFS regulations?
June 17, 2014
The "Since You Asked" Committee received a request to clarify if Medicare FFS allows hospitals to roll back admit to inpatient orders. The requester indicated that the practitioner initially placed the patient in observation. After 16 hours the case was reviewed by the case manager, and patient was deemed inpatient. The requester wanted regulatory guidance to confirm whether or not the “admit to inpatient” order could be rolled back to the start of the admission.
An inpatient stay begins on the day a patient is formally admitted to a hospital with a practitioner's order. Medicare does not permit retroactive orders. The order must specify the admitting practitioner's recommendations to admit to "inpatient," or similar language indicating their recommendation for inpatient care. The order to admit to inpatient is a critical part of the physician certification. The physician certification is required for inpatient coverage and payment under Part A. The "admit to inpatient" order, physician certification and appropriate documentation in the medical record of medical necessity are required to provide evidence that hospital inpatient services are appropriate.
Source:
Department of Health & Human Services
Centers for Medicare & Medicaid Services
January 30, 2014
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-01-30-14.pdf
ACMA invites members to pose
questions to the “Since You Asked” Committee
by emailing Nancy Loeffler, chair of the
committee, at nancy.loeffler@inova.org.
What are Medicare Requirements for Physician Documentation?
June 2, 2014
The “Since You Asked” Committee received a request to address the problem regarding physician documentation requirements. The requester is noticing a trend at her hospital that admitting physicians are not completing the history and physical on the day of admission; instead they are waiting until the next calendar day as well as not writing a progress note for hospital day 2. The physicians are under the impression that the history and physical written on hospital day 2 is sufficient. The concern expressed is the lack of physician documentation on day of admission may be insufficient to support hospital billing. The requester is seeking regulatory guidance.
Medicare published medical documentation guidelines for evaluation and management services in 1995 1, 3 and 1997 2, 3. General principles state medical record documentation is required to record pertinent facts, findings and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments and outcomes. This serves as a chronological record of patient care and is an important element contributing to high quality care. Appropriate medical record documentation can reduce many of the hassles associated with claims processing and serves as a legal document to verify the care provided.
The four main purposes of medical record documentation facilitate:
- The ability of the physician and the health care team to evaluate and plan the patient’s immediate treatment and monitor patient care over time,
- Communication and continuity of care among physicians and the health care team,
- Accurate and timely claims review and payment, and
- Collection of data that may be useful for education and research.
Medicare Utilization Review Conditions of Participation state admissions may be reviewed before, during or after hospital admission as stated in the hospital’s UR plan 4. Best practice for case management professionals is to perform a utilization review before or at the time of admission to determine if medical necessity for an inpatient admission is demonstrated. If medical necessity is not demonstrated, steps to invoke Condition Code 445 must be completed prior to a written discharge order or release. Condition Code 44 allows the physician to change the inpatient bedding order to outpatient services order.
State Medical Boards may govern the timing and frequency of physician documentation, and these requirements will vary from state to state. The hospital’s medical staff bylaws will set the requirements for the physician practice. The Medical Executive Committee oversees the development, revision and adoption of the medical staff bylaws. Medical staff bylaws will include documentation elements outlined by Medicare regulatory guidance.
Case management professionals should have access to the medical bylaws regarding medical documentation requirements. Knowing the requirements assists in determining when a medical documentation variance exists. This knowledge will allow case managers to stimulate discussions with physician and hospital leaders when a practice may no longer support the changing health care environment.
Sources:
11995 Documentation Guidelines for Evaluation and Management Services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MNEdWebGuide/Downloads/95Docguidelines.pdf
21997 Documentation Guidelines for Evaluation and Management Services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MNEdWebGuide/Downloads/97Docguidelines.pdf
3Evaluation and Management Services Guide. December 2014. www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval_mgmt_serv_guide-ICN006764.pdf
4Revise Appendix A, “Interpretive Guidelines for Hospitals”. CMS Manual System. Pub. 100-7 State Operations Provider Certification, Department of Health and Human Services (DHHS) Centers for Medicare and Medicaid Services (CMS). Transmittal 37. October 17, 2008. www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R37SOMA.pdf
5Clarification of Medicare Payment Policy When Inpatient Admission Is Determined Not to Be Medically Necessary, Including the Use of Condition Code 44: “Inpatient Admission Changed to Outpatient”. MLN Matters Number: SE062. Related Change Request (CR)#: 3444. Related CR Release Date: September 10, 2004. www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE0622.pdf
ACMA invites members to pose
questions to the “Since You Asked” Committee
by emailing Nancy Loeffler, chair of the
committee, at nancy.loeffler@inova.org.
How does the hospice benefit coordinate with a Medicare Advantage plan?
May 19, 2014
Hospice Benefit and Coordination with Medicare Advantage
When a Medicare Advantage enrollee elects to begin receiving hospice benefits any care and/or services related to their terminal diagnosis are paid by hospice. Hospice is paid a per diem by Medicare to cover the care related to the terminal illness. Care that is unrelated to the terminal illness and other traditional Medicare services will be covered by traditional Medicare. If the Medicare Advantage plan offers additional services not covered by Medicare then the Advantage plan will continue to provide those services.1
Revocation of the Hospice Benefit
When a patient revokes hospice, they are choosing to no longer receive their hospice benefit. At the time of revocation, care for all services resumes under traditional Medicare coverage unless the patient was enrolled in a Medicare Advantage plan at the time of hospice election. In that case, all claims will be paid by traditional Medicare until the first of the month following revocation. At that time, all coverage will revert back to the Medicare Advantage plan.2
Proposed Changes
In their 2014 report to Congress, the Medicare Payment Advisory Commission (MedPAC) recommended that Medicare Advantage plans assume both the financial and clinical management of the hospice benefit. Some of the features of this proposed “carve in” of hospice include: offering a limited network of providers, allowing Medicare Advantage plans to increase beneficiary cost sharing, requiring prior authorization for services, and allowing individual rate reimbursement negations between Medicare Advantage plans and individual hospice agencies.3, 4
Going Forward
The National Hospice and Palliative Care Organization opposes MedPAC’s current recommendation to “carve in” the hospice benefit for a variety of reasons including the potential to further complicate coordination of care and the potential to limit patient and family choice with regard to hospice provider. As more patients elect Medicare Advantage plans, it is crucial that case managers be educated on the coordination of this benefit and the future implications of regulatory changes.
Sources:
1Centers for Medicare and Medicaid services. “Medicare Hospice Benefits”. CMS Product No 02154. http://www.medicare.gov/Pubs/PDF/02154.pdf Revised August 2013
2 Centers for Medicare and Medicaid services. “Medicare Hospice Benefits”. CMS Product No 02154. http://www.medicare.gov/Pubs/PDF/02154.pdf Revised August 2013
3 Hospice and the Medicare Advantage “Carve In”. Hospice Action Network. www.hospiceactionnetwork.org 2014
4MedPAC “Hospice Services” March 2014 report, Chapter 12 http://www.medpac.gov/chapters/mar14_ch12.pdf March 2014
5Hospice and the Medicare Advantage “Carve In”. Hospice Action Network. www.hospiceactionnetwork.org 2014
ACMA invites members to pose
questions to the “Since You Asked” Committee
by emailing Nancy Loeffler, chair of the
committee, at nancy.loeffler@inova.org.
April 21, 2014
In October 2012, the Centers for Medicare and Medicaid Services (CMS) introduced a separate penalty program, which stemmed from the Affordable Care Act, that reduced payments to hospitals with excess 30-day readmissions for heart attack, heart failure and pneumonia patients. A readmission generally refers to an admission to an acute care hospital within 30 days of a discharge from the same or another acute care hospital.
Excess readmissions are measured by a ratio, by dividing a hospital’s number of “predicted” 30-day readmission for heart attack, heart failure and pneumonia by the number that would be expected, based on an average hospital with similar patients. A ratio greater than 1.00 indicates excess readmissions. This data is risk adjusted, meaning it takes into account how sick patients are based on their age, gender and co-morbid conditions. The CMS readmission penalty is 2% of a hospital’s Medicare base operating DRG (Diagnostic Related Groups) payments in 2014 and increases to 3% for 2015 and beyond.
Organizations across the country are using many different tactics to prevent re-admissions. One of the most common procedures is multi-disciplinary rounding in which patients are discussed with all team members and the best plan for sustaining discharge is discussed and put in place. The acute care case managers may include home health nurses and case managers, county social workers, transportation companies to ensure that the patient keeps a follow-up appointment, and family members in the care plan.
Other organizations are using case managers in the outpatient setting within their medical groups and clinics. The case managers follow the patients post-discharge anywhere between 30 and 90 days depending upon the patients’ co-morbid conditions, services needed, compliance with medications, and the treatment plan. Case managers in the acute care setting may also include case managers in the patient’s insurance plan. The insurance case managers follow the patient for utilization, costs, and if local, may meet with the patient in the clinic setting.
Telephonic and face-to-face follow-up with the patient on a regular basis are essential elements in preventing readmissions. Case managers are the essential elemental contact in consultation with the physician assisting the patient in following a care plan. They are the experts in discharge planning and care coordination.
Whatever measures your organization is using to prevent readmissions, it is certain to include the basic case management principles such as proper screening and assessment, planning, care coordination, and evaluation. Following the case management process is the heart and soul of sustained discharges.
ACMA invites members to pose
questions to the “Since You Asked” Committee
by emailing Nancy Loeffler, chair of the
committee, at nancy.loeffler@inova.org.
What is an NCD or LCD, and why does it matter?
March 19, 2014
Payers establish benefit coverage documents as a means to communicate to providers the items and services covered and the supporting clinical criteria required for compliant billing. Medicare coverage is limited to items and services that are considered reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category).1 Medicare's benefit coverage documents are referred to as National Coverage Determinations (NCDs). NCDs are developed through an evidence-based process and include a public comment period before the final NCD is published. There are items and services that may not have a published NCD. In those instances, a Local Coverage Determinations (LCDs) may provide guidance. An LCD is developed at the discretion of Medicare contractors.
Medicare monitors providers to detect fraud and abuse activity. Generally, fraud is defined as making false statements or misrepresentations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist.2 Examples of Medicare fraud may include knowingly billing Medicare for an item or service that was not furnished or knowingly altering claim forms and/or receipts to receive a higher payment.
Medicare abuse is defined as a practice that directly or indirectly result in unnecessary costs to Medicare and includes any practice that is not consistent with the goals of providing patients with services that are medical necessary, meet professionally recognized standards or fairly priced.3 Examples of Medicare abuse are misusing codes on a claim, excessive charging for services or supplies or billing for services deemed to be not medically necessary.
Providers who engage in fraud and abuse practices are exposed to criminal and civil liability. If a provider has been convicted of Medicare fraud and abuse, those providers are excluded by Medicare, Medicaid and other federal health care programs to pay the provider for items or services for a designated period.
How do I find an NCD or LCD?
The Centers for Medicare and Medicaid Services (CMS) provide access to the Medicare Coverage Database through CMS.gov website. This database contains all NCDs and LCDs, local articles and proposed NCD decisions. There are several ways to search for a document. Search options include document ID, key word (s), CPT/HCPCS code and by document type. Follow this link for the Medicare Coverage Database: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx/
Summary
Payers publish coverage benefit documents and Medicare’s documents are known as National Coverage Determinations and Local Coverage Determinations. Providers need to be informed of the coverage determination requirements in order to submit complaint claims for items and services. Providers who demonstrate a pattern of fraud and abuse are subject to criminal and civil penalties including exclusion from receiving payments from Medicare, Medicaid and other Federal health care programs for a designated period.
References:
1 http://www.cms.gov/Medicare/Coverage/DeterminationProcess/index.html
2,3 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.Pdf
ACMA invites members to pose
questions to the “Since You Asked” Committee
by emailing Nancy Loeffler, chair of the
committee, at nancy.loeffler@inova.org.
What does it take to be compliant under the new discharge planning rules?
February 12, 2014
On May 17, 2013, the Centers for Medicare and Medicaid (CMS) released the new Conditions of Participation for Discharge Planning. There are thirteen essential elements to the new release and all of them affect our daily work. The emphasis is on screening and assessment, planning, documentation, and readmission evaluation. The Scope of Services and the Standards of Practice released by ACMA in 2013 address the same items and mirror the same professional conduct when interacting with our patients and their families. We encourage you to take a moment to review the requirements, understand them and use them in your daily practice. For a complete explanation of the essential elements, CMS has published a PDF to view.
To view the PDF, click here.
The thirteen essential elements are as follows:
- The hospital must have in effect a discharge planning process that applies to all inpatients. The hospital’s policies and procedures must be specified in writing.
This includes a four stage process as listed:
- Screening all inpatients to determine which ones are at risk of adverse health consequences post-discharge if they lack discharge planning;
- Evaluation of the post-discharge needs of inpatients identified in the first stage, or of inpatients who request an evaluation, or whose physician requests one;
- Development of a discharge plan if indicated by the evaluation or at the request of the patient’s physician; and
- Initiation of the implementation of the discharge plan prior to the discharge of an inpatient
- The hospital must identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning.
- The hospital must provide a discharge planning evaluation to the patients identified and to other patients upon the patient’s request, the request of a person acting on the patient’s behalf, or the request of the physician.
- A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of, the evaluation.
- The hospital personnel must complete the evaluation on a timely basis so that appropriate arrangements for post-hospital care are made before discharge, and to avoid unnecessary delays in discharge.
- The hospital must discuss the results of the evaluation with the patient or individual acting on his or her behalf.
- A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of a discharge plan if the discharge planning evaluation indicates a need for a discharge plan.
- In the absence of a finding by the hospital that a patient needs a discharge plan, the patient’s physician may request a discharge plan. In such a case, the hospital must develop a discharge plan for the patient.
- The hospital must arrange for the initial implementation of the patient’s discharge plan with the consent of the patient and family based on preferences and choice.
- The hospital must reassess the patient’s discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan.
- The hospital must include in the discharge plan a list of HHAs or SNFs that are available to the patient, that are participating in the Medicare program, and that serve the geographic area (as defined by the HHA) in which the patient resides, or in the case of a SNF, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available.
- The hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care.
- The hospital must reassess its discharge planning process on an on-going basis. The reassessment must include a review of discharge plans to ensure that they are responsive to discharge needs.
ACMA invites members to pose
questions to the “Since You Asked” Committee
by emailing Nancy Loeffler, chair of the
committee, at nancy.loeffler@inova.org.
What is prepayment review, and what does it mean for me?
January 15, 2014
The RAC Prepayment Review is a RAC Demonstration Project that is still ongoing. The purpose of the project is to prevent improper payments before they are made, in contrast to the standard RAC process where money already is paid but will be recouped after retrospective review. This is expected to lower the payment error rate with the focus being on claims with higher improper payment rates.
The states selected for the project are the seven states identified as fraud and error prone. Those states identified are California, Florida, Illinois, Louisiana, Michigan, New York, and Texas. There are four states with the highest volume of short inpatient stays defined as two days or less. Those states are identified as Michigan, North Carolina, Ohio, and Pennsylvania.
The initial prepayment review was for 15 high-volume inpatient MSDRGs, of which 11 are cardiac procedures with the balance of the procedures related to orthopedics. One hundred percent of these procedures are undergoing prepayment review for the appropriateness of the procedures which can delay payment to the facility for up to 60 days. If any of the required elements are missing, the claim will not be paid.
The unique aspect of this process is that if the hospital is denied payment, any payment the physicians have received will be recouped even if the hospital is appealing the denied claim. For the first time, there now is alignment of hospital and physician payment whereas, in the past, a denied hospital claim did not result in a denied physician claim.
The two areas being scrutinized prior to payment are if the procedure was medically appropriate and justified, and in the case of the selected orthopedic procedures, several elements were scrutinized to ensure that proper conservative treatment methods were attempted three months prior to the procedure. Proper documentation of the conservative treatment is essential for payment of the procedure.
Historically, many orthopedic procedures were done with the comment that the patient “failed conservative therapy,” but the duration of this therapy was never defined and could have been a mere two weeks of NSAID treatment. With certain back operations, there is clear evidence that at one year’s time, the outcome of pain relief is very similar when compared to conservative, non-surgical treatment, although pain relief may occur sooner with the surgical procedure. This is the rationale for the required documentation to support the prolonged conservative treatment. As previously stated, the prepayment review could take as long as 60 days. This process could have a major impact on hospital cash flow since the procedures being reviewed are frequently cardiac and orthopedic procedures.
We realized that the old generic histories and physicals used in the past would not be adequate to justify the procedures under prepayment review and would result in denied hospital claims and subsequent recoupment of any physician payments. For that reason we developed a number of checklists for each of the procedures at risk that were based on long coverage determinations (LCDs) when available, and we included all the needed information to justify the procedures.
We educated the medical staff on the project and informed them that a procedure could not be scheduled without the appropriate check list being completed. The checklist for ortho procedures included X-ray findings, type and duration of NSAID treatment, etc. Without such documentation, the scheduled procedure would be cancelled. After a period of time we made recommendations to the physicians that they develop a template for their H&Ps that would document all the elements necessary to justify the procedure and prevent any hospital denied claims and subsequent recoupment of physician payment. This process was successful primarily because the physician payment was now aligned to the hospital payment.
ACMA invites members to pose
questions to the “Since You Asked” Committee
by emailing Nancy Loeffler, chair of the
committee, at nancy.loeffler@inova.org.
What is a good method for achieving positive outcomes during tense conversations?
December 11, 2013
During the holidays expectations and tensions can run high. Patients want to be home with their families, and families worry about caring for their loved ones at home during this hectic season. Crucial conversations surrounding complex medical conditions and difficult decisions for discharge and end-of-life issues become more critical at this time of the year. Case managers must work and communicate collaboratively and efficiently to achieve a positive outcome for their patients and the organization they serve. Effectively holding conversations when the stakes are high begins by understanding what elements constitute a crucial conversation. For answers to that question, we turn to a publication entitled, Crucial Conversations, written by Patterson, Grenny, McMillan and Switzer in 2002. The book offers a guide to mastering difficult conversations and situations.
Crucial conversations are dialogues between two or more people when stakes are high, opinions vary and emotions run strong. Effectively handling these conversations includes avoiding silence or violence. Providing a safe environment for everyone is a key concept because it enables information to be shared and forms a mutual purpose to gain results.
Prior to engaging in a crucial conversation, one must look inside oneself or examine his or her intent. The focus must be on what needs to be accomplished without sacrificing integrity and without creating a volatile situation that can sabotage the end result. “Fight-or-flight” tendencies, wanting to “win,” seeking revenge, or keeping the peace do not end in a positive result for either party. The end goal should not be an “either/or” situation but a situation that incorporates the positive contributions brought by both sides during the conversation.
Identifying the moment at which the conversation becomes crucial and whether the participants feel safe is paramount to fostering an open dialogue and providing a free flow of information. Creating this atmosphere leads to information one may not have heard before and helps to create a shared pool of information with informed decision making based on facts versus conclusions.
One needs to master emotions and not become hostage to them. Avoid the “victim,” “villain” or “helpless person” scenario in a situation. However, if a situation escalates to abuse or sexual harassment, one should contact someone in authority to intervene.
Starting a dialogue begins with sharing your view and speaking persuasively not abrasively. Help others to understand a point of view by these simple steps known as STATE:
- Share your facts
- Tell your story
- Ask for others' paths
- Talk tentatively
- Encourage testing
Explore others’ paths through the use of power listening skills known as AMPP:
- Ask
- Mirror their emotions when their words and actions differ
- Paraphrase their response
- Prime them by guessing as to how they feel
Dialogue provides a shared pool of information but does not mean that everyone shares in the decision making. A designated decision maker should be appointed, and others need to be assigned tasks and timeframes and be held accountable for the outcomes delivered to obtain results.
In Summary: Identify when conversations become crucial, examine intent, create dialogue and allow the free flow of information. Remember to maintain safety, identify what you want, what others want and what will build the relationship. Then, move to action and decision making.
The book Crucial Conversations provides tools that can help prepare a case manager for collaboration and success in the workplace and should be in an essential component of the case manager’s library.
ACMA invites members to pose
questions to the “Since You Asked” Committee
by emailing Nancy Loeffler, chair of the
committee, at nancy.loeffler@inova.org.
What is the new LTCH rule for admission?
November 20, 2013
The Centers for Medicare & Medicaid Services (CMS) released the final FY 2014 Long-Term Acute Care Hospital (LTCH) PPS Proposed Rule extending the 25 Percent Rule to all LTCHs. An LTCH may no longer admit more than 25 percent of its patients from the “host” hospital or any one short term acute care hospital, or it risks not receiving full payment for Medicare services (CMS.gov). The 25 Percent Rule decreases expenditures to LTCHs that surpass conventional percentage thresholds for patients admitted from any one referring hospital during a cost-reporting period (Medpac.gov.). The purpose of the rule is to safeguard LTCHs from functioning as acute care hospitals while ensuring admission decisions to LTCHs are clinically based, not merely financial decisions.
The Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) markedly transformed the 25 Percent Rule. Initially, the rule applied only to LTCH host hospitals, confining the proportion of Medicare patients admitted from the host hospital during a cost reporting period. The rule was phased in over three years, with the inception fixed at 75 percent for FY 2006, 50 percent for FY 2007, and 25 percent for FY 2008 (Medpac.gov.). Once the threshold is reached, LTCHs are subsequently reimbursed the lesser of the LTCH PPS rate, or the short-term acute care hospital PPS rate.
Background:
LTCHs care for patients with often serious chronic medical challenges requiring intense inpatient care extending more than 25 days. The LTCH patient is part of a swiftly increasing population who survived an acute critical illness with constant multiple organ failure, often requiring elevated intensity of specialized care. Patients found in LTCHs in retrospect reveal the skill of contemporary medicine allowing prolong life despite continuing life threatening and multi-organ failure (MacIntyre, 2012). In 1981 intensive care units for critically ill patients incurred approximately $15 billion, resulting in the need for LTCHs. A major source of these costs resulted from patients who were difficult to wean off ventilators, often exceeding the suggested length of stay for the assigned DRG; therefore, these patients were responsible for much of the surfeit expenditures in acute care facilities (Saqr, Mikhail, & Langabeer, 2008). Further, as monetary inducements became evident, LTCHs increased significantly from 90 LTCHs in 1990 to 363 LTCHs in 2005, from 90 LTCHs. As of 2010, there were 434 LTCHs in the United States, with Select Specialty Corporation operating approximately 111 and Kindred Healthcare operating approximately 83, both identified as industry leaders (Koranne, 2011).
LTCH admission criteria will be outlined in a future addition of “Since You Asked.” In the meantime, please feel free to contact the author regarding the 25 Percent Rule or any LTCH questions at pehawkins@selectmedical.com.
References:
CMS.gov. (2013)
Koranne, R. (2011). The role of the long-term acute care hospital. Minnesota Medicine, 94(9), 38-40.
MacIntyre, N. R. (2012). Chronic Critical Illness: The Growing Challenge to Health Care... 49th Respiratory Care Journal Conference, “The Chronically Critically Ill Patient,” Florida. Respiratory Care, 57(6), 1021-1027.
Medpac.gov. (2009).
Saqr, H., Mikhail, O., & Langabeer, J. (2008). The financial impact of the Medicare prospective payment system on long-term acute care hospitals. Journal of Health Care Finance, 35(1), 58-69.
ACMA invites members to pose
questions to the “Since You Asked” Committee
by emailing Nancy Loeffler, chair of the
committee, at nancy.loeffler@inova.org.
Community Acquired Pneumonia (CAP)…When is hospitalization appropriate?
October 30, 2013
Community Acquired Pneumonia (CAP) can be managed in the outpatient setting. There are times when it is appropriate to hospitalize these patients. Case Managers are tasked with applying objective clinical criteria such as InterQual® or Milliman Care Guidelines to guide medical necessity determinations for appropriateness of the treatment setting and level of care. There are times when the patient’s clinical condition indicators fall short in meeting the medical necessity for hospitalization. Cases that do not meet the medical necessity criteria for the setting and/or level of care should be referred to a secondary physician reviewer.
An additional piece of information that a case manager could provide to the secondary physician reviewer is Pneumonia Severity Index (PSI) score and/or the CURB-65 score. These prospectively validated clinical prediction tools, endorsed by The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA), assist the physician to determine which setting, outpatient or inpatient, is clinically appropriate for the patient.
The PSI has 20 variables such as age, sex, comorbid disease, physician exam findings and laboratory findings and includes whether or not the patient is a nursing home resident. Generally, outpatient therapy is recommended for risk classes I and II. To access the Pneumonia Severity Index calculator, follow this link: http://pda.ahrq.gov/clinic/psi/psicalc.asp.
The CURB – 65 is an easier tool to calculate and interpret at the point of care. Five variables are considered and they are Confusion, Urea Nitrogen, Respiratory rate, Blood pressure, > 65 years or older. One point is assigned for each clinical positive feature. The clinical parameters found in this tool correlate with InterQual’s critieria at the acute care level. A score of > 3 suggests an inpatient setting. To access the CURB-65 electronic calculator, follow this link: http://www.mdcalc.com/curb-65-severity-score-community-acquired-pneumonia/.
These tools are intended to support clinical judgment, not to replace it. There are many factors that need to be considered in order to determine the most appropriate clinical setting to meet the patient’s clinical needs.
Reference:
Ebell, M. (2006). Outpatient vs. inpatient treatment of community-acquired pneumonia. Family Practice Management, 13(4), 41-44. Retrieved from http://www.aafp.org/fpm/2006/0400/p41.html
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