The use of “Observation Status” – treating certain hospitalized Medicare patients as outpatients when their care is indistinguishable to the GCM, family and patient from that of formally admitted inpatients - continues to garner considerable attention It remains an unresolved problem that has serious financial consequences for Medicare patients and their families despite recent public and Congressional attention. The question is what can you as a Care Manager do to advocate for this aspect of your clients care coordination: 1. Understand the difference between Traditional Medicare vs. a Medicare Advantage Program Most Medicare Advantage programs have elected to have different “rules” than Traditional Medicare with a Medigap supplement and your approach will be different for a Medicare Advantage insured. This explains the difference which will not be addressed in this article. medicarerights.org/fliers/Medicare-Advantage/Differences-Between-OM-and-MA.pdf?nrd=1 2. Make friends with the ER Care Manager and your client’s assigned Floor/Unit Case Manager Case managers are the experts in status determination and are familiar with the nuances. They are the ideal professionals to partner with. They review the patient record, physician documentation, therapies, and test results to properly determine an observation status. If the client has both a Social Worker CM and a RN CM assigned, you want to speak with the RN CM as they typically are the ones reviewing the record and determining medical ER Case Manager: Not all hospitals have one, but when they do you should be making contact with this person when your client is being seen in the ER. They will be able to tell you the admission status of your client and why. As a retired ER CM, I would speculate to say 80% of people over the age of 75 are being admitted to OBS status as they are not meeting admission criteria in their short ER stay. Determine the admission status of your client within 12 hours of admission so you can be proactive in assuring either conversion to admission within “2 midnights” or discharge home. 3. Familiarize yourself with the guidelines most hospital CM’s and Insurance Carriers use so you can “talk the talk” to better advocate for your client. There are national guidelines published in the Medicare Benefit Policy Manual for determining who is assigned to inpatient status, and who is assigned to observation status. These guidelines are vague yet complex and can change every year, so most hospital CM’s and insurance companies use a service that publishes criteria to help them apply the guidelines to each patient. Two of the most popular services are McKesson’s InterQual Criteria and Milliman Care Guidelines. These inpatient and observation guidelines typically address two different types of criteria. The first criterion is the severity of your illness (SI Criteria): are you sick enough to need inpatient admission? The second criterion is the intensity of the services you’re requiring (IS Criteria): is the treatment you need intense enough or complex enough that a hospital is the most cost efficient place you can safely receive that treatment? Each criterion point has a whole slew of very specific evaluation points which might include things like blood test results, X-ray findings, physical exam findings, and the types of treatments you’ve been prescribed. Your client’s assigned RN CM will evaluate the case, look at the doctor’s findings, diagnosis, results from tests and studies, and prescribed treatment and compare it to these national guidelines. He or she will then use those guidelines to suggest to the doctor to assign either observation status, or inpatient status. Also be aware in cases where there is not an ER CM, your client may be admitted as an inpatient and then in the AM when a RN CM is assigned, the status will be converted to OBS. This is referred to as applying “Condition Code 44.” https://cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R299CP.pdf 4. Advocating for your client when OBS status of greater than “2 midnights” is imminent Since you are familiar with the criteria the CM is using, ask them if your client’s status can be converted to inpatient and/or what is preventing this…IS it the IS or SI criteria? Offer to help in any way you can to assure the conversion to inpatient occur before the deadline. If they are not meeting criteria and can safely go home, request a discharge and provide the CM with your safe discharge plan There are usually two scenarios: 1. If they are not meeting criteria or but you feel cannot safely go home (make sure your decision is based upon clinical facts and the National Criteria) Frequently it is due to poor documentation in the medical record by those providing care. See if you can determine the cause of not meeting the criteria and offer to help resolve this. 2. Still being kept in OBS but meeting criteria If the CM/hospital insists on Observation Status, ask for a written notice stating this fact Tell the hospital the patient wants to appeal the Observation Status – because the care is “medically necessary” and an “inpatient hospital level of care.” 5. What to do if your client is no longer in the hospital: The patient might be able to appeal. Unfortunately, winning Medicare coverage in Observation cases is difficult. Try to get the patient’s physician to assist. Here is a link for more detailed instructions on how to appeal: medicareadvocacy.org/self-help-packet-for-medicare-observation-status/ 6. The financial implications OBS status in a hospital: When hospital patients are classified as outpatients on Observation Status, they may be charged for services that Medicare would have paid if they were properly admitted as inpatients. For example, patients may be charged for their medications. (Thus, people may want to bring their medications from home if they have to go to the hospital.) Outpatient Observation Status is paid by Medicare Part B, while inpatient hospital admissions are paid by Part A. Thus, Medicare beneficiaries who are enrolled in Part A, but not Part B, will be responsible for their entire hospital bill if they are classified as Observation Status. Most significantly, patients will not be able to obtain any Medicare coverage if they need nursing home care after their hospital stay. Medicare only covers nursing home care for patients who have a 3-day inpatient hospital stay – Observation Status doesnt count towards the 3-day stay. (This rule most likely will not apply to those with a Medicare Advantage plan) Conclusion Observation Status has the potential to cause financial and physical harm to clients of Care Managers with Traditional Medicare insurance when they are hospitalized, especially those who need to continue their recovery in a SNF. Congress or CMS should act now to solve this problem. Meanwhile, as a Geriatric Care Manager, you can follow the above guidelines to advocate on your clients behalf. Barbara Kolonay RN MS CCM is the President of Options For Elder Care, a Geriatric Care Management practice located in Pittsburgh PA. Bobbi has over 35 years of progressive experience in the insurance/hospital case management industry and is available for conferencing or presenting on care management . optionsforeldercare
Posted on: Sun, 21 Sep 2014 02:58:28 +0000
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