MAC mobile reviews an eye-opening experience

Nurses scrutinized records on site

The first time Winthrop University Hospital in Mineola, NY, experienced a mobile review from National Government Services, New York’s Medicare Administrative Contractor (MAC), the panel of three nurses reviewed 20 cases on site and denied claims for all 20 cases. When they visited the 591-bed teaching hospital again three months later, the nurses upheld every claim.

In between visits, the hospital expanded case management coverage, provided extensive education on documentation requirements to providers, revised the language in the computerized physician order entry, revised the pre-surgical utilization review process, and implemented a process in which physician advisors review every one-day stay covered by Medicare fee-for-service, says Maureen Gaffney, RPAC, RN, senior vice president of patient care services and chief medical information officer for the Long Island hospital.

Some MACs have begun sending teams of nurses to hospitals for on-site reviews of hospital records instead of reviewing the records in the office without interacting with the hospital staff. Winthrop Medical Center was the first hospital in the state of New York to receive a review.

In November 2011, the MAC, National Government Services, sent the hospital a list of 20 cases that would be reviewed by a panel of three nurses during a two-day onsite visit. The 20 requested charts were all for one-day stays that had occurred during 2011.

Three weeks later, the nurse reviewers showed up, held an opening conference with hospital staff, spent two days reviewing the charts, then met with hospital officials for a post-review conference, giving feedback on why they denied the claims.

After the initial Recovery Audit Contractor (RACs) audits, Winthrop identified its top overpayment issues: surgical cardiovascular procedures, such as drug-eluting stents; percutaneous cardiovascular procedures; all risks and mortality levels of syncope; surgical cardiovascular procedures without coronary artery stent; and chest pain.

Most of the cases the nurses selected for review were from that list and included chest pain, syncope, and stents. Two cases were for one-day stays for surgical procedures.

“The nurses were very intimidating and very resistant to any of our discussion about our rationale for admitting these patients. They said the documentation needed to be more explicit about what the physicians were thinking and pushed observation status for the patients instead of one-day stays,” Gaffney says.

Winthrop’s RAC experience has been complicated by the fact that the State of New York requires a disposition of every patient who comes into the emergency department within eight hours. It’s a challenge in an emergency department that experiences more than 70,000 emergency department visits in a year.

In addition, until last year, the state Department of Health required that Medicaid patients had to be put in a dedicated observation unit, and not in a regular patient bed. The requirement has been rescinded.

“The nurses were not sympathetic about our challenge with complying with the Department of Health rules on observation for Medicaid patients and said it didn’t matter. They informed us that Medicare patients can be observed in scatter beds. Placing an outpatient in an inpatient bed presents complex operational issues that were not appreciated by the reviews,” Gaffney says.

The review nurses denied 80% of the cases they reviewed on site and threatened the hospital with prepayment review if there were any problems when they returned in three months.

Based on the audit, the hospital determined that the pre-surgical utilization review process was broken, case management was not adequate in the emergency department, the “admit to” language in the computerized physician order entry was problematic, that extended recovery orders needed to be clarified, and that case managers needed to cover every point of entry to manage the appropriate level of care.

Case managers now cover the emergency department 16 hours a day to assist physicians in determining medical necessity for admissions and patient status.

The hospital also assigned case managers to all departments where patients enter the hospital, including the ambulatory surgery unit, the cardiac catheterization lab, and the gastroenterology lab. “We have case managers where physicians may have concerns or patients have complications after outpatient procedures. Instead of admitting these patients, we extend the recovery time and keep them in ambulatory status. It’s simply a billing issue. We still provide the same care,” she says.

The hospital provided extensive education on documentation requirements to the case management team, the physicians, and the clinical documentation improvement team and changed processes, such as the surgical utilization review process. “We had to re-teach the clinicians to document using the same language that the coders and auditors speak. It’s very different from what they learned in medical school or other educational programs,” she says.

The hospital added alerts and indications for admission within the electronic medical record and redesigned the admissions process to enhance documentation, Gaffney says. Now the physician advisor reviews every Medicare fee-for-service short-stay patient to identify opportunities for improvement in the process and documentation.

When the team of three nurses came back three months later and brought their medical director, the hospital was ready for them. Representatives from the Hospital Association of New York State and the Greater New York Hospital Association were present, along with the hospital’s physician leadership. Before the meeting, the case management team had reviewed the 20 requested charts as if they were appealing the cases and attached an appeals letter to every chart.

The MAC review team upheld every chart. In addition, the denials the mobile MAC auditors issued during the first mobile review were appealed by the hospital and subsequently overturned by the administrative law judge.

“We learned a lot throughout the whole process. We made a lot of changes and believe we are doing the right thing for the patients,” she says.