Downgrades of short inpatient stays to observation status by recovery audit contractors can lead to big losses in reimbursement. This is forcing hospitals to look more closely at their patient-status decisions, according to Steven J. Meyerson, MD, vice president of physician advisory services at Accretive Health. In a Q&A in the RAC Monitor, Dr. Meyerson provided six points on how hospitals can make the right decision about inpatient status and avoid RAC take-backs.
1. What ED physicians should do. Since many short-stay patients come through the ED, emergency physicians should develop a realistic approach on how to handle these cases. Of course, they must perform the relevant tests, such as a history and physical and an EKG. But "once the physician decides the patient can't be discharged from the ED, the admitting physician needs to do a risk stratification," Dr. Meyerson said.
2. Adhere to the clinical concerns. Physicians who evaluate the patient should not be swayed by non-clinical concerns. "Defensive medicine on the part of ED physicians may make them more reluctant to discharge patients who could be managed in an office setting," Dr. Meyerson said. Also, a lack of primary care physicians for follow-up care encourages treating and working these patients up in the hospital.
3. Develop a protocol for such patients. The hospital should develop a protocol for managing low- to moderate-risk patients coming from the ED and elsewhere. Since the evaluation of these patients can take 24 hours or more, they should be placed in outpatient observation status. "It would not be appropriate to extend an emergency room visit for this duration," Dr. Meyerson said. "In addition, the hospital will see additional revenue if it bills for observation services instead of an ED visit."
4. Track length of stay. Hospitals should track length of stay of observation patients and review this data daily for admission and discharge. "Few should remain in observation beyond 48 hours," Dr. Meyerson said. Segregating observation patients into observation units improves timeliness of their workups.
5. There is no right mix of case managers. Providing enough case managers to oversee this process is important, but Dr. Meyerson would not recommend a certain ratio of case managers to patients. There are many variables, such as the percentage of Medicare patients; what staffing, scheduling, training models are used; and the mix of nurses and social workers, he said.
6. Status can't change after discharge. Physicians are allowed to change the patient's status from inpatient to outpatient status but only if the patient is still in the hospital. This requirement is meant to ensure patients are fully informed about the change in status, because it would impact their co-insurance and deductible payments.
Read the RAC Monitor report on recovery audit contractors.
Learn more about Accretive Health.
Related articles on use of observation status:
"Observation" Care Puts Hospitals, Patients at Odds Over Medicare Requirements
5 Lessons From CMS on RAC Medical Necessity Denials