Ensuring that patients meet admission criteria

One-day stays focus in RAC demonstration project

Of the nearly $1 billion the Recovery Audit Contractors (RACs) identified in improper payments to hospitals and other providers, nearly 40% was the result of medical necessity denial for inpatient admissions, points out Deborah Hale, CCS, president, Administrative Consultant Service LLC, a Shawnee, OK, consulting firm.

Much of the focus was on one-day stays simply because a one-day stay is at the highest risk of being medically unnecessary, she adds.

To prepare for the RAC audits in your hospital, Hale suggests analyzing your one-days stays to determine where you may have vulnerability.

At the same time, case managers should keep in mind that not all one-day stays are medically unnecessary.

"Each case must be evaluated based on evidence-based screening criteria and, ultimately, the opinion of a physician applying clinical judgment," Hale says.

Physicians and the UR process

Case managers should be aware that just because a case doesn't initially meet admissions criteria, it doesn't mean that it is medically unnecessary.

"That's where the physicians on the utilization review committee come in. They can make a clinical judgment based on the patient's severity of illness, his or her past medical history, and other factors and override the determination that the patient's condition doesn't meet admission criteria," she says.

However, she points out, the documentation must be present in the medical record and should include the severity of the patient's presenting signs and symptoms, any appropriate past medical history, the physician's assessment of why inpatient admission was medically necessary, and the patient's medical stability for discharge, she adds.

During the RAC demonstration project, cardiac-related one-day stays — such as those associated with cardiac catheterization procedures or chest pain diagnoses — yielded significant findings and RAC identification of overpayments, says Carol H. Eyer, RHIA, CHC, senior manager of clinical compliance with Pershing Yoakley & Associates' Atlanta office.

"Nothing says that the areas the RACs focused on during the demonstration project will be the same areas of focus with the permanent RAC program. However, based on the RACs' success in identifying significant overpayments during the demonstration project, it's likely that their focus will continue in these areas as well as expanding to include others," she says.

Typically, cardiac catheterization patients don't meet medical necessity criteria for staying over-night unless they develop complications, adds Lorraine Larrance, BSN, MHSA, CPHQ, CCM, manager with Pershing Yoakley.

"The determination about admitting patients following cardiac catheterizations is typically made in the catheterization laboratory environment by a physician who may or may not understand the admission criteria or whether the patient should be a 'bedded overnight' as an outpatient, placed in observation status, or admitted as an inpatient. Since case managers don't typically work in the outpatient environment, there is a risk of the patients being mis-assigned to a level of care that isn't appropriate and isn't supported by clinical necessity," she says.

Physician orders for inpatient admission following a nonemergent elective cardiac catheterization without documented complications should be a red flag to case managers on medical necessity, Eyer says.

During the demonstration project, the RACs also reviewed a lot of charts for medical necessity when patients had one-day stays for chest pain, Eyer says.

Many patients with chest pain are admitted in inpatient status and discharged within a 24- to 36-hour period, which may not be the appropriate level of care, she adds.

"Patients with negative enzymes or no factors pointing to a definite heart attack more often meet observation status criteria, but the emergency department doctors and nursing staff are not always trained to know that. Without a case manager in the emergency department reviewing the admission status, there is a danger that the patient could slip through the cracks," she says.

When a patient is admitted, make sure the physicians include documentation in the chart to support their rationale as to why it is medically necessary to keep the patient overnight as an inpatient, Eyer suggests.

This provides the foundation for success with an appeal if the RAC determines that there was an inappropriate payment, particularly with one-day stays, she says.