Audits highlight need for documentation
Executive Summary
The Centers for Medicare & Medicaid Services’ "Probe and Educate" initiative to determine hospitals’ compliance with the two-midnight rule makes it clear that case managers must review physician documentation as well as medical necessity.
• The Medicare Administrative Contractors are focusing on short stays when physician documentation doesn’t support the expectation of a two-midnight stay.
• They’re looking at flawed admission orders, and when the orders to admit are issued by a practitioner who does not have admitting privileges at the hospital.
• Another area of focus is physician statements without documentation of the reason for the need for inpatient treatment.
Probe and Educate audits are in force
The "Probe and Educate" initiative by the Centers for Medicare & Medicaid Services (CMS) has made it clear that case managers have a bigger responsibility than ever before to make sure their hospitals receive appropriate reimbursement for the services they provide, says Kurt Hopfensperger, MD, JD, senior medical director for Executive Health Resources, a Newtown Square, PA-based healthcare consulting firm.
"Case managers now need to look at all the elements of physician documentation as well as reviewing for medical necessity of care and do so for every single case. Physicians must document and justify the expected length of stay, write why the patient needs inpatient medical care, and include a plan for post-hospital care. It all has to be on the chart and signed before patients are discharged," he says.
Probe and Educate is a prepayment review by the Medicare Administrative Contractors (MACs) to determine hospitals’ compliance with CMS’ two-midnight rule. Post-payment audits for the two-midnight rule have been postponed until after March 31, 2015, but hospitals still have to meet the requirements, Hopfensperger says.
During their reviews, the MACs have zeroed in on short-stay procedures not on Medicare’s Inpatient Only list and short stays when the record doesn’t support the expectation of a two-midnight stay, Hopfensperger says.
"Medicare requirements say that a two-midnight expected stay must be supported by physician documentation. Support must be in the notes and not just a boilerplate statement or a stamp," he says.
Flawed orders
The MACs also are looking for flawed orders for admission, Hopfensperger says. Physicians no longer can write just "admit" but should use more specific language such as "admit as an inpatient," he says.
"We have reviewed a significant number of charts for our hospital clients and found that the MACs have denied claims when the order is not signed by a certified physician," he says.
Emergency department physicians no longer can make an independent decision to admit a patient if they don’t have admitting privileges, he says. However, in some hospitals, nurse practitioners and physician assistants may meet the requirements, he adds.
The MACs are also focusing on general physician statements without medical recommendations, he says. The reasons patients need inpatient treatment must be backed up by physician documentation, he says.
CMS has announced its intention for the MACs to avoid auditing cases on the Medicare Inpatient Only list and concentrate on other short-stay medical and surgical cases.
Originally, CMS expected the Probe and Educate program to last three months, then six months. Now it’s slated to last for 18 months, until March 31, 2015.
For Probe and Educate, the MACs send hospitals a letter requesting additional documentation on a sample of up to 10 charts for small hospitals and 25 charts for larger hospitals. The charts are for stays that are less than two midnights after formal admission and that occurred between Oct. 1, 2013, and March 31, 2015. "There may be instances when patients were in the operating recovery room or the emergency department over a midnight but the stay appeared to be just one midnight because the patient had not been formally admitted," Hopfensperger says.
After the MACs review the hospital claims, they categorize the hospitals based on how many of the sample cases were denied. When only 10% of the claims have errors, the hospitals receive a summary letter with details on claims that were denied and why and will not receive additional reviews under the "probe and educate" process, he says.
The MACs send hospitals with errors in 20% to 60% of claims a detailed letter explaining each denial and offer a one-on-one phone call to discuss the denials. Then the MACs conduct a second set of "probe and educate" reviews on the same number of charts, he says.
Hospitals with errors on 70% or more of the claims receive a letter with details of each denial, and an offer of a one-on-one educational telephone call. The MACs then request a second set of charts. If the problem persists, the MACs will repeat the audit and will request 10 times the original number of charts, he says.
"If hospitals don’t get it right, they can be at risk for audits of a large number of charts," he says.
The hospital can schedule a telephone conference with the reviewer who denied the cases or with one of the MAC staff to go over each case and discuss why it didn’t meet the requirements for payment.
Most of the hospitals opt for the conference, he says. "They want to hear directly from the reviewer and be able to ask questions," Hopfensperger adds.
