Clarifying the Increased CMS UR Standards

Transcription

1 Clarifying the Increased CMS UR Standards Friday, May 9 th, 2014 Speaker Sue Dill Calloway RN, Esq AD, BA, BSN, MSN, JD CPHRM President of Patient Safety and Health Care Consulting Board Member Emergency Medicine Foundation Dublin, Ohio sdill1@columbus.rr.com 2 1

2 Learning Objectives 1. Explain why hospitals must have a UR plan. 2. Discuss the importance of physician documentation regarding medical necessity in medical records. 3. Describe why hospitals are required to have a UR Committee. 4. Explain new and revised standards, regulations, and laws put forth by CMS, TJC and the federal government. 5. Evaluate compliance requirements and penalties. 3 The Conditions of Participation (CoPs) Regulations first published in 1986 CoP manual updated February, 2014 and 456 pages long Tag numbers are section numbers and go from 0001 to 1164 First regulations are published in the Federal Register then CMS publishes the Interpretive Guidelines and some have survey procedures 2 Hospitals should check the CMS Survey and Certification website once a month for changes

3 New website at 5 CMS Hospital CoP Manual als/downloads/som107_ Appendixtoc.pd 6 3

4 Mandatory Compliance Hospitals that participate in Medicare or Medicaid must meet the COPs for all patients in the facilities Not just those patients who are Medicare or Medicaid Hospitals accredited by TJC, AOA, CIHQ, or DNV Healthcare have what is called deemed status This means you can get reimbursed without going through a state agency survey Can still get complaint or validation survey 7 How to Keep Up with Changes First, periodically check to see you have the most current CoP manual 1 Once a month go out and check the survey and certification website 2 Once a month check the CMS transmittal page 3 CMS reserves the right to tinker with the language in a survey memo and when finalized publishes it in a transmittal Have one person in your facility who has this responsibility

5 CMS Survey and Certification Website iongeninfo/pmsr/list.asp#to pofpage 9 CMS Transmittals

6 Access to Hospital Complaint Data There is a list that includes the hospital s name and the different tag numbers that were found to be out of compliance Many on restraints and seclusion, EMTALA, infection control, patient rights including consent, advance directives and grievances and standing orders Two websites by private entities also publish the CMS nursing home survey data and hospitals The ProPublica website for LTC The Association for Health Care Journalist (AHCJ) websites for hospitals 11 Access to Hospital Complaint Data 12 6

7 Updated Deficiency Data Reports Certification/CertificationandComplianc/Hospitals.html 13 The CMS Hospital CoPs on Utilization Review 14 7

8 CMS CoP Utilization Review The Utilization Review section (abbreviated UR) starts at tag 652 Has not been updated in long time TJC amended the leadership chapter (LD ) to require a UR plan and UR committee with at least two physician members Added 2 EPs to comply with the MIPPA or Medicare Improvements for Patient and Providers Act The Discharge Planning session starts at tag 699 The final discharge planning standards were effective July and was 39 pages 15 CMS CoP Utilization Review Also called Utilization Management or UM Although UM describes a more proactive and concurrent process that seeks to ensure appropriate and efficient use of healthcare resources which includes managing quality and the cost of services Utilization review is by definition a process of looking backwards to determine if the healthcare diagnosis and treatment was appropriate or appropriately applied as well as a review of services provided Quality is linked with utilization review and management and CMS has a QAPI section and worksheet 16 8

9 Utilization Review Important in healthcare for many reasons Making sure quality care is provided In most cost effective manner To reduce hospital admissions and length of stays Want to make sure care is medically necessary especially in light of the RACs or recovery audit contractors and the two midnight rule Hospital should make sure has good UR plan and UR staff So what s in your UR plan and in your UR program?? Should update it on an annual basis 17 Two Midnight Rule It is not in the CMS CoP It is part of the billing manual However, still important to establish medical necessity If patient is expected to stay at least two midnight then presumption that it is appropriate to admit the patient as an inpatient as long as not gaming the system If less then presumption it is an outpatient observation patient 18 9

10 Two Midnight Rule Important to meet the documentation requirements Decision based on complex medical factors as beneficiary medical history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk (probability) of an adverse event occurring during the time period for which hospitalization is considered Physician signs the order and a certification Law passed delaying it 6 months and RACs on vacation Order should read: Admit an inpatient to 7 tower or Place in an outpatient observation bed 19 CMS FAQs on Two Midnight Rule Programs/Medical-Review/Downloads/Questions_andAnswersRelatingtoPatientStatusReviewsforPosting_31214.pdf 20 10

11 Many CMS Memos on 2 Midnight Rule 21 Admission Order & Certification 22 11

12 Physician Certification

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14 Utilization Review Plan 27 Utilization Review Policy 28 14

15 Utilization Review Critical Access Hospitals Currently Medicare reimbursement for CAHs is not based on DRG designation so not subject to mandatory reviews No similar UR section in the CAH manual for Medicare patients However, Rural Healthcare Quality Network (RHQN) recommends hospitals conduct internal reviews using the InterQual criteria if possible (many private insurers use) Recommend this even though other criteria sets are available and less costly Notes that in the future mandatory reviews may become a reality 29 Utilization Review Certification (justification) may be required for certain procedures or a hospital stay before an insurance company will pay for the stay LOS usually assigned by physician or nurse reviewer, hospital committee, insurance provider or a combination of the four Medicare reviewers currently use InterQual criteria when reviewing medical records to establish if inpatient admissions were medically necessary InterQual (or Milliman-USA) criteria are used by case managers when conducting inpatient utilization review 30 15

16 Utilization Review InterQual criteria are clinically based on best practice, clinical data and medical literature The criteria are updated continually and released annually The criteria is the first level screening tool to assist in determining if the proposed services are clinically indicated and in the appropriate setting Can t be use to deny a case as only physicians determine clinical appropriateness If does not meet then case is referred to a physician reviewer for further determination of medical necessity 31 Utilization Review Hospital and the attending physician will have the opportunity to provide additional information on the inpatient Medicare patient that may not have been available to the physician reviewer Of course, case may still be denied and there will be opportunity to request a review by a different physician reviewer If second physician reviewer denies it then opportunity to have case reviewed by an administrative law judge (ALJ) If denied, Medicare takes money back for payment of the hospital stay 32 16

17 QIO Role in UR This is why it is important for hospitals to respond back to notices in a timely manner This is the amount of time indicated on the letters received from the Quality Improvement Organizations or QIOs The QIO does the peer review activity for CMS Every state has a QIO under contract by CMS QIO is involved with the Scope of Work (SOW) which is updated every 3 years 9 th SOW started August 2008 thru July 31, 2012 and 14 states worked on care transition project (See MedQic) 33 Medicare Quality Improvement Org Program The Medicare QIO program was created by law in 1982 to improve quality and efficiency of services to Medicare patients First phase in the early nineties did this through peer review (PRO) to identify cases where professional standards were not met for initiating corrective actions In second phase, had significant changes with how to improve care and promotion of public reporting and development of scope of work projects 34 17

18 CMS and Quality of Care IOM March 2006 report recommended changes and CMS makes improvements as result of the MMA Law Medicare Prescription Drug, Improvement, and Modernation Act of 2003, section 109(d)(1) CMS views QIO program as the cornerstone to improve quality and efficiency for Medicare patients CMS undertaking activities to manage and measure quality and they want value based purchasing and has a roadmap More under discharge planning 35 CMS Roadmap for Quality Measurement 36 18

19 9 th Scope of Work SOW Many times surveyor will ask to see if the hospital has signed a contract with their QIO to participate in the SOW Many times if this is done CMS surveyor may not scrutinize the UR standards 14 states worked on the Care Transition Project to promote seamless transition across settings including hospital to home and to prevent readmissions Ten focus areas; heart failure, MRSA, pressure ulcers, R&S, AHRQ culture tool, surgical care, drug safety, public reporting, LD and quality assessment tool Focused disparities (diabetes) and chronic kidney disease 37 9 th Scope of Work SOW QIOs will continue to review quality of care given to Medicare patients, beneficiary appeals of certain notices, potential EMTALA, and implementing QI activities as a result of case reviews, sanctions etc. Some states adopted some of the initiatives Some measures overlap with IHI (Institute for Healthcare Improvement) 5 Million Lives Campaign and 100K live campaign Some also overlap with American Heart Association on the Get with the Guidelines campaign (GWTG) 38 19

20 Medical Necessity CMS takes the position that whether a patient should be admitted as an inpatient is a complex medical judgment that should be made by the physician based on; Severity of the signs and symptoms exhibited by the patient, Medical probability of an adverse outcome for the patient, and The need and availability of diagnostic studies See MLN Matter SE CMS Guidance on Hospital Inpatient Admissions Medical necessity is a hot button with the RACs, Medicare Administrative Contractors (MACs), fiscal intermediaries (FIs) and comprehensive error rate testing (CERT) contractors CMS released an educational guideline to assist hospitals regarding inpatient admission decisions To help ensure that hospitals are using proper screening criteria to analyze documentation and make medical necessity determinations Chapter 6 of the Medicare Program Integrity Manual, Section 6.5 is available at on the CMS website 40 20

21 Transmittal SE1037 1/25/ Medicare Program Integrity Manual Guidance/Guidance/Manuals/downloads /pim83c06.pdf 42 21

22 Medicare Benefits Policy Manual nloads/bp102c01.pdf 43 Inpatient Review for Medicare Patients A tool used by the QIO may be helpful to determine medical necessity but does not guarantee payments for admission or continued stay Demographics Patient name, ID number Attending Name and contact information The day or dates under review SI (symptom intensity) How sick is the patient? This places the patient s services in context with their clinical condition and is needed both for the initial review and for concurrent review 44 22

23 Medical Necessity Symptom intensity (continued) What is the main clinical issue? Abnormal vital signs? Pain present- where, what is the cause? Neurological status: alert to obtunded Brief description of diagnostic tests (especially if lab or x-rays are abnormal) Any consultations and evaluations or procedures? 45 Intensity of Services IS (Intensity of services) What care is the patient receiving? IV medications and frequency Any IV PRN meds given for nausea, pain? How often each day? IV Fluids/ TPN Blood or blood products (should have a HCT as a reason) Oxygen needed? FiO2 and route? ABGs done or O2 sats? 46 23

24 Discharge Screens DS (Discharge Screens) What is the longterm plan? An unsafe discharge will initiate a quality of care review. What is the expected destination after hospitalization? What discharge planning activities are being done What care needs are there post discharge? Educational Needs? Are there any significant psychosocial issues? 47 Intensity of Services Intensity of Services continued Diet/Tube feeds/gavage (what is infants weight) If patient is on a sliding scale, What were the high/low glucose values? How many coverage units were given on each day (not the routine doses)? Wound management: describe wound and dressing/debridement/special issues Any other treatments or therapies? 48 24

25 Information on the QIOs Initiatives-Patient-Assessment- Instruments/QualityImprovementOrgs/ index.html?redirect=/qualityimprovem entorgs

26 List of all QIOs 51 Utilization Review A-0652 Hospital must have a UR plan that provides for review of services furnished by the institution and the members of the MS to Medicare and Medicaid beneficiaries UR plan should state responsibility and authority of those involved in the UR process Surveyor will make sure activities performed as in UR plan Need to include review of medical necessity of admissions 52 26

27 Utilization Review Review of medical necessity for: Appropriateness of the setting Extended stays and Professional services rendered This is really important in light of the Recovery Audit Contractors or RACs American Hospital Association, AHIMA, and CMS has website of resources for the RACs RAC program to identify improper Medicare payments including overpayment and underpayments 53 AHA Website on RAC Program s/rac/index.html 54 27

28 CMS RAC Website ms.gov/rac

29 Survey Procedure Tag 652 These are the questions to the surveyors to verify Determine that the hospital has a utilization review plan for those services furnished by the hospital and its medical staff to M&M patients. Verify through review of records and reports, and interviews with the UR chairman and/or members that UR activities are being performed as described in the hospital UR plan. Review the minutes of the UR committee to verify that they include dates, members in attendance, extended stay reviews with approval or disapproval noted in a status report of any actions taken. 57 UR Plan UR Plan should say who is on the UR committee Such as the physician advisor, CNO, discharge planners, social services, business office manager, HIM director, administration, UR nurse, billing office, etc. Should discuss meeting frequency such as meets once a month It should address conflicts of interest so anyone with financial interest in the hospital can not be on the committee Should include a confidentiality section so all data, minutes, worksheets are confidential 58 29

30 Functions of a UR Committee Should include functions of the UR committee such as: To establish and carry out a program of admission certification and continued stay review of all patients in accordance with applicable state and federal laws and regulations To supervise the utilization review activities of non physician reviewers To assure coordination between concurrent review activities, quality assurance, and risk management activities, and reimbursement agencies 59 Functions of the UR Committee To assist in the selection and ongoing modification of criteria and standards To recommend changes in hospital procedures, medical Staff practices or continuing education programs as indicated on analysis of review findings To act on any topics referred to them by the Medical Staff, Administration, or any other hospital committee To address potential over-utilization or under utilization issues 60 30

31 UR Plan UR plan can include the method of review All patients admitted to the hospital will reviewed by the UR nurse for appropriateness and medical necessity Includes M&M patients, CHAMPUS, patient insurance covered by private contract, self pay, etc. What guidelines are used such as InterQual or Milliman etc. Concurrent reviews are done using the same criteria or the information provided by the insurers If criteria does not exist then will work with physician and patient and family to move the patient to the appropriate level of service 61 UR Plan If UR nurse sees unusually high costs or frequent ordering of excessive services then can talk to physician advisor Or can subject case to Preadmission Review or indepth peer review Decisions made by UR nurse will be based on standards adopted by the MS and QIO Include in the policy the preadmission review process Precertification of elective surgeries should be done by the physician s office but hospital will verify precert Include admission review process 62 31

32 Utilization Review Make sure you get observation rules correct especially with condition code 44 and two midnight rule CMS issue UR CoP Memo June 2, 2007 Exception for UR plan is if the Hospital has an agreement with the QIO in their state to assume binding review Hospitals may have a contract with QIO to review admissions, quality, appropriateness and diagnostic information related to Medicare inpatients Surveyor will look to see if hospital has a signed contract with their state QIO 63 Composition of UR Committee 654 Consists of 2 or more practitioners who carry out UR function At least 2 members must be doctors The UR committee must be either a staff committee of the hospital or A group outside that has been established by the local medical society for hospitals in that locale and established in a manner approved by CMS 64 32

33 UR Committee 654 A committee may not be conducted by an individual who has a direct financial or ownership interest (5% or more) or Who was professionally involved in the care of the patient whose case is being reviewed Surveyor will look to see if the governing board has delegated UR function to a outside group if impracticable to have a staff committee 65 Frequency of Review 655 UR plan must provide review for Medicare/Medicaid (M/M) patients with respect to medical necessity Admissions (before, at, or after admission) Usually should screen within one working day of admission and use severity of illness or intensity of service as discussed previously Duration of stay Professional services furnished including drugs and biologicals 66 33

34 Scope of Reviews A-0655 Reviews may be on a sample basis except for reviews of cases assumed to outlier cases because of extended stay cases or high costs Surveyor will examine UR plan to determine if medical necessity is reviewed P&P should state what to do such as UR nurse speaks with attending, goes to the physician reviewer, when ABNs are issued, IM Notices, QIO guidelines etc. If IPPS hospital there should be a review of the duration of stay in cases assumed to be outlier 67 Admissions or Continued Stay Determination that admission or continued stay is not medically necessary is made by one member of UR committee if the physician concurs with determination or fails to present their views when afforded the opportunity Must be made by two members in all other cases (656) Before determination not medically necessary, UR committee must consult the MD responsible for the care and afford opportunity to present their views 68 34

35 Hospital Discharge Summary Form 69 Admissions or Continued Stay Then committee must provide written notification no later than two days after determination to the hospital, patient and practitioner responsible for care If attending doctor does not respond or contest the findings of the committee, the findings are final If physician of UR committee finds not medically necessary no referral of committee is necessary and he may notify the attending doctor If non-physician makes the determination it must go to the committee or the physician reviewer A non-physician can not make this final determination 70 35

36 Review of Professional Services 658 The committee must review professional services provided To determine medical necessity And to promote the most efficient use of available health facilities and services Topics for the committee may include overuse or underuse of necessary services Timeliness of scheduling of services such as diagnostic and operating rooms 71 This presentation is intended solely to provide general information and does not constitute legal advice. Attendance at the presentation or later review of these printed materials does not create an attorney-client relationship with the presenter(s). You should not take any action based upon any information in this presentation without first consulting legal counsel familiar with your particular circumstances

37 The End! Questions??? Sue Dill Calloway RN, Esq. CPHRM, CCMSCP AD, BA, BSN, MSN, JD President of Patient Safety and Education Consulting Board Member Emergency Medicine Patient Safety Foundation