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CMS has been trying for several years to clear up the confusion about which patients should be admitted as inpatients and which should receive observation services as outpatients, but the new rules seem to make it more difficult to understand.
The solution to getting patient status right is to have case managers in the right places to review the cases of patients who are coming into the hospital, says Beverly Cunningham, RN, MS, consultant and partner at Oklahoma-based Case Management Concepts.
Patients receiving observation services can fall through the cracks and stay in the hospital longer than necessary if there’s not a way for the treatment team to easily distinguish between them and admitted patients.
If you’ve got a system for getting patient status right up front and it works, don’t change anything but make sure that the documentation is detailed and complete, advises Linda Sallee, RN, MS, CMAC, ACM, IQCI, director for Huron Healthcare with headquarters in Chicago.
As we have discussed in prior editions of Case Management Insider, the 2010 Affordable Care Act was a game changer for the healthcare system. The payment reforms it introduced began the process of requiring health systems to communicate across the continuum of care and to reduce and/or eliminate existing silos. This across-the-continuum integration required sharing of accountability for cost and quality of care among providers.
The move by CMS to change the payment methodology for patients receiving observation services means it’s more important than ever for case managers to ensure that patients receive the services they need in a timely manner and that they receive only the care they need while they are in an acute care setting, says Amy M. Smith, RN, MSN, CCM, director of case management at Dartmouth-Hitchcock Medical Center, a 421-bed academic medical center in Lebanon, NH.
Hospitals across the country have filed lawsuits challenging the decision by CMS to reduce Medicare reimbursement by 0.2% to compensate for the financial effect of the Two-Midnight rule.
Dartmouth-Hitchcock Medical Center in Lebanon, NH, reviews every patient at every point of access to make sure that they are placed in the correct status.
Financial Disclosure: Managing Editor Jill Drachenberg, Associate Managing Editor Dana Spector, and Editor Mary Booth Thomas, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Nurse Planner Toni Cesta, PhD, RN, FAAN, Consulting Editor of Hospital Case Management, is a consultant with Case Management Concepts LLC.
