with Part 1. Bev Cunningham has been a partner and consultant with Case Management Concepts, LLC, since its inception. Previously, Bev served as the Vice President, Resource Management, at Medical City Dallas Hospital, where she was responsible for case management, health information management, patient access, solid organ transplant, and transplant financial services. Bev has been involved in the development of case management for over 25 years, and her areas of expertise include the role of the case management in the revenue cycle, compliance for case management departments, the role of the physician advisor, and effective denials and appeal management. Bev has achieved ACM certification by the American Case Management Association. And then Dr. Tony Sesta is a founding partner of Case Management Concepts, LLC, which is a consulting company that assists institutions in designing, implementing, and evaluating case management departments and models, educational programs, and on-site support for leadership and staff. Dr. Sesta has been active in the research and development of case management for more than 25 years, and her research has included two funded studies measuring the effects of a case management model on congestive heart failure and fractured hip patient populations, with measures of patient satisfaction, quality of life, and short and long-term clinical perceptions and outcomes. We are so thankful to have you both here with us this morning. We invite you to go ahead and get us started with part one. Well, thank you, Lindsay, so very much. And, you know, I'm the new gal here, for those of you that have been hearing Tony for years, but here she is with me. Good morning, Tony. Hello, Bev, and we have a wonderful group, a wonderful group, and we're so happy to have you leading the charge on utilization management. It is, you know, so fun, and I think everybody's going to enjoy it today. And you and I have been working together a long time, a long time, folks. I know, but did I hear you say utilization management is going to be fun? Well, because you're leading the charge, and you will make it fun, I'm quite sure. Oh, my goodness. I'm setting the bar very high for you this morning. Oh, yeah, thank you so much. You're welcome. Well, we have been business partners for a very long time, and so we hope you enjoy our presentation today. We're going to get deep into it, but this first webinar is really going to cover the basics of it. And so, when you think about case management and you think about the four basic roles that happen in the case management process, the case management role, certainly utilization management that we're going to talk about today, resource management, of course, discharge and transitional planning, and then care coordination. And every one of them have a very, very important role in what the case manager does. But I just have to tell you, I love utilization management. I love rules and regs. I love denials and appeals. So, that's where Tony is coming from. So, let's talk for just a minute and be a little bit interactive. And just in your chat, I know Lindsay says for the Q&A, for your questions, put them in the Q&A. But in the chat, just pop in the top three UM challenges that you have. Probably some of them are going to be very similar. Some of them may be very different depending on what your role is. If your role is solely dedicated to the utilization management process, you may have some different challenges than the case manager that's out on the unit and is incorporating case management or, excuse me, utilization management into his or her role. So, what are the kinds of things we're seeing in the chat? I can't see the chat. So, Tony or Lindsay? I see authorizations, timely pre-certs, finding qualified candidates, advantage plans, utilization management and care coordination don't always agree, which leads to conflict, need to build teamwork, admitting to correct level of care from the start, authorization approvals, payer delays, and authorization provider documentation to support medical necessity, advantage plans, additional approved days, providers, advantage plans. I'm seeing a trend here. I do believe that, yes. And caps, yeah. Yes, yep. That is true. Well, thank you for, I think it's good for everybody to see what everybody else is dealing with because, you know, advantage plans, whether it's Medicare or Medicaid, but specifically, you know, next week we're going to be talking about Medicare advantage plans and their role in the two-midnight rule that came in to be the responsibility they have that are, you know, that are happening that where they have to go along with the two-midnight rule and, of course, lots of challenges. We are going to do some polls, so be ready for that. If you're in a group with people, talk quickly amongst yourselves and see if you can come to an agreement on what you want to put as the answers. There's no right or wrong for these, but what this does is help Tony and I know what's going on in your different areas and with you individually so that we can really move into getting to the meat that you're interested in as well. So, let's talk about utilization management and some of the definitions that we hear. So, often you are, utilization review, the conditions of participation by Medicare and Medicaid services, oh my goodness, they still use the term you are. Utilization management, medical necessity, but the whole bottom line to this is it's just a process of how you're going to see if that patient should be in the hospital, are they appropriate in the level of care that they're in, and then how does that relate to the beneficiary of that particular payer. And if you've been around, and we've been around for a while, we've seen how that has changed from medical necessity was far more cut and dried than it is now where each of the individual payers kind of have their own definitions and their own way that they look at medical necessity and utilization management. So, you are as passive. You just do it, you're done. Utilization management is active and operational. So, as you look at yourself, what do you really do when you're looking at that medical necessity piece? Are you being proactive? Are you reviewing? Are you talking to the healthcare team? And somebody mentioned the collaboration and the challenges between utilization management and care coordination. It does align with the other roles of the case manager that we talked about, and it does require some critical thinking. And of course, from the time that I started as a nurse case manager many, many years ago, where it was pretty cut and dried, and I didn't have to do a lot of critical thinking, our patients are far sicker, our treatments are far more advanced, and the way we look at medical necessity is very different. And then, as I mentioned earlier, it just requires a lot of flexibility related to the very different payers we have and their reimbursement structures. So, let's go back to UR. We said it's passive. It's really auditing physician documentation, but utilization management then is doing something about that audit. We're going to talk about what that something really is. Now, medical necessity, if you want to really get down to the nitty-gritty with it, it is really no more or no less than what the patient requires at a specific point in time. So, what we really want to look at is what level of care should be billed based on where that patient is and what level of care is appropriate for them. And are we doing more things than we really need to? Tony, you know we do not like complementary colonoscopies in the hospital, so medical necessity is important. That's where we're going to look at it. So, let's talk about a few different levels that you might see. So, inpatient, and I think we all pretty get what an inpatient is, the order should read admit as inpatient, not admit to One South or to ICU, but admit as inpatient. Observation should really read place an observation service, not admit to observation. CMS, including many other payers, when they see the word admit, they almost don't go any further and they assume you mean inpatient. Outpatient in a bed is that patient that I'm sure many of you deal with every day, and probably if you're in the ED, you deal with it even more. But that's a patient that doesn't meet medical necessity. Maybe it's a late recovery after surgery, but it's really too late to send them home. They really don't need to necessarily be observed as far as observation service is concerned, or it could be a social issue where the patient can't go home. It's really not safe for them to discharge. Maybe there's nobody there to take care of them that night and you're going to work on it the next morning, but that is going to be your outpatient in a bed. Let's talk about patients that are being held in the ED. There's two different kinds of patients held in the ED. One is waiting for transfer to a higher level hospital, and you want to leave that patient in the ED level of care because when they're in the ED level of care, they continue to meet the EMTALA guidelines for a transfer to a higher level of care. That aspect is very important. If you flip them to inpatient, then that takes away the EMTALA guidelines from them. But if you have a patient that's being held in the ED waiting for placement in your hospital bed, go ahead and put them as an inpatient or place them in observation service, whichever is appropriate. But one of the advantages if you're holding patients is that if they're inpatient and they're going to need that three midnight qualification for a skilled nursing facility placement, this can begin to give you the first midnight or first couple of midnights depending on how long you're going to have to hold them so that you're able to transition them more quickly if that actually is the requirement. So let's talk about integrating these UM principles into your case management practice. So first, is the current setting appropriate? Is it essential? And is it related to the reason that the person is in that setting? Now, if you're from a psychiatric hospital, in a few slides, we are going to talk about psychiatric medical necessity. But I will tell you, I would suggest that you don't zone out on either, regardless of what camp you're in, because each of them have really nice verbiage that is very appropriate. And I think the psych medical necessity guidelines do have some really good, some good use of verbiage that will be helpful to all of us. Is efficient and effective cost care, excuse me, let me say that again, cost effective and efficient. Well, my word, I can't even talk today. Cost effective and efficient patient care is the key. Tonya, I don't know what happened there. I know. Hey, Bev, I know I'm getting a chat question. And I don't know if you want to be interrupted or you want to wait till the end. I'm not I wasn't sure what you wanted to go ahead if you want to. Okay. Okay. Did you want to read? Yeah, yes, I'm reading it. How does ER bed licensure factor into updating class to inpatient or OBS for patients holding in the ER waiting for inpatient bed in our hospital? Okay, I'm sorry. Yeah. How did you? Yeah. How does ER bed licensure factor into updating class to inpatient or OBS for patients holding in the ED waiting for inpatient bed in our hospital? Okay. Okay. I get it. I don't think I do you think it is? I don't think it does. But okay, I'll let you answer. You're right. Yeah, that's a very good question. I think it's maybe a legal question. But sometimes we just have to hold patients. And unfortunately, that's just what happens when we get really busy. My understanding and Tonya, it sounds like you agree on this is that an inpatient holding in the ED does not have any impact on your licensure for the number of ED beds that you might have. Yeah, I think perhaps what Emily is getting at is since it's an ED, but you're holding patients waiting for beds. It's not a factor because, well, one of the reasons that the Joint Commission came out with the patient flow standard was to this exact point. Because if you move a patient from ED to an inpatient bed, but they're still in the ED, you must be sure you're providing an inpatient level of care. So in other words, you don't want the ER nurses just running around doing emergencies. There has to be a proper management of that inpatient or OBS patient. We don't like to see OBS patients in the ED unless, I mean, I suppose maybe you have a dedicated area for OBS, but otherwise they shouldn't be really waiting for a bed unless the hospital is completely full. And if that's happening a lot, that's a bigger problem, Emily, if you're holding lots of patients in the ED all the time. But net net, the ED knows that they should be providing a different level of care. In other words, what the nurses are doing and how they're managing that care of that patient. And frankly, in an ED, it could be almost, you know, the complement of patients to the nurse is usually pretty good in the ED, but the ED nurse monitoring and managing that patient has to be accounted for. So it's documentation also. So I hope I answered that question. You can always email us later if you need additional information. It's an excellent question. Thank you. Well, it is. And Tony, you know, I think I would even expand on what you said, because if there's a patient being held in the ED, then we would expect the ED case manager to begin the assessment and to continue any medical necessity reviews and communicate with the payer if that is something that's required. So yeah. Yeah, she added this. Does the hospital slash ED have to be accredited to bill inpatient OBS level of care within the ED? No, the CMS used to care where the patient was physically located. So in other words, if you had an inpatient in the ED, that could be problematic in terms of billing. But they have changed that. Now they don't care where you have the patient. So you could have the patient in the ED, you could have them on the roof, you could have them anywhere you like and bill, but you have to bill from a compliance perspective for the right level of care. I think maybe that's what you were getting at. So no, you should bill the level of care that the patient is at based on those physician admission orders that Bev was just showing. Thank you. That is great. Although you had me cracking up here on the roof. We did see that during the COVID times that patients were everywhere. So absolutely. Then on the third big bullet, attending physician has to be included in the review. And I think sometimes we do see this happening where if you review a patient, you review the medical necessity, you review the medical necessity, they don't meet medical necessity, then make sure that the very next step is that you have to look at what can the physician add. And, you know, we see people skipping this process, but we need to go back and we need to have a physician discussion. Is there anything more than you can add? You know, we are nurses, we are the first level reviewers, excuse me. And I, like Tony, I'm a registered nurse as well. And then you also want to review lab, review, x-ray, procedure reports, all of the reports that are suggested here, any orders to support your conversation with the physician and then relate them, relate the medical necessity to where that patient is. So if they're in ICU and they need to be meeting ICU medical necessity, then you're going to be looking at that particular medical necessity. Now, just like the ICU, you may have a patient that no longer meets ICU medical necessity and then you're waiting for a bed and there's no bed in your step-down or in your med-surg floors and you're holding that patient in ICU and that really comes into the billing process because you need to be billing the appropriate medical necessity that patient is meeting, step-down or intermediate med-surg and then also in the NICU levels of care as well. Okay, let's play this or that. You don't even have to answer this except in your head because you probably will feel like we're harping on this and we don't mean to be harp, harp, harp, but we kind of do, is a patient doesn't meet medical necessity on your first level review. What is your first step? So based on our previous slide, the answer would be which? I think it would be this, speak with the attending physician regarding the possibility of additional documentation or that discuss the situation with the physician advisor. And we'll talk through this process about how you get to that conversation with the physician advisor. I will say that a physician that is taking care of a patient should really not be surprised that a physician advisor comes to talk to them. If you've talked to that physician and there's nothing else, then you say, you know what? I'm gonna have to escalate this to our physician advisor. There appear they may be able to understand this better than I about if this patient is going to meet medical necessity. So forget popping your answer in the chat and let's talk about performing medical necessity. Well, so on admission, we wanna see did that patient meet medical necessity? Somebody said, that's one of the big of the UM issues that you face. Do they need to go inpatient or? Yes ma'am. We have a question. Okay. I'm sorry, I'm interrupting. Can you provide resource for defining or guiding guidance on topic of medical necessity qualifications? Yes, we can. Interqual or Millman or any other set of guidelines that you use in your hospital. Thank you. And we'll talk about, that is a good question. We're gonna talk about that in just a little bit. I will say, Tony, we do, I know we agree on this. Medical necessity guidelines are not your gut feeling about what's going on with the patient. Or what you memorized five years ago. Yes, exactly. Unfortunately, we have seen that. So the kind of questions you're gonna be asking are these that are listed here. Why is the patient in the hospital? How sick are they? What treatment are they receiving? What is it about that patient that can only be treated in your hospital? Or what treatment is being provided that can only be done there? And then kind of on the converse, is there something that's being done that could be done in another level of care? Skilled nursing, acute rehab or something, yeah, acute rehab, home, home care. And then last but not least, is the patient expected to stay at least two midnights? So the two midnight rule, I kind of breezed across this just a little bit ago, but as of the first of this year, the two midnight rule applies to both traditional Medicare patients and Medicare Advantage patients. Also the two midnight rule, and we'll definitely talk more about this next week, applies to psychiatric hospitals, critical access hospitals, acute hospitals. So there we go. Okay, and then once you decide where that patient should be on admission, inpatient, observation, service, outpatient and a bed, then you wanna determine the medical necessity during the stay. And the constant questions you're going to be asking is that patient sick enough to stay or are they stable enough to be discharged to a post-acute level of care? And what clinical situation could only be treated in your hospital? And the same questions that we had before, what treatment is being provided that can only be done in your hospital? And not unimportant at all, and one that we face so much is, is there a safe discharge plan? So we really do see hospitals where medical necessity is only done on admission, especially for Medicare patients, traditional Medicare patients. And then they're just kind of allowed to, a word that I do like to use is languish in the hospital. And what's happening is there's nobody really focusing on, do they need to go home or not? Or do they need to go to another level of care? And so it's very important that medical necessity during the hospital stay is continued. So here is a slide that really makes us stop and think. Don't stop and assume that you know if medical necessity has or has not been met. Like Tony said, just because you knew Interpol several years ago, I'll just give you an example. We had a, we were working with the hospital and we were actually implementing, they were implementing our recommendations, but we were talking to some of the RN case managers and one, she happened to be a traveler, nothing against travelers by any means at all, but she just said, oh, you know what? I've done it, I know it. I don't even have to use any sort of medical necessity criteria. Well, that's, it's not, that's just not how it works. Okay, so the process points that we want to get to is what are you going, where are you going to look? What are you going to do to determine medical necessity? Well, of course, what's the medical record say? And oh my gosh, how does the patient look? Now to know how the patient look means, looks means that you must go into the patient room. Now that is, that's a challenge. If you are a, you are a nurse and you're maybe remote or you're maybe remote, whether it's offsite or someplace else in the hospital, pardon me, and you're not seeing the patients, a huge, huge reason to have the very, very best collaboration that you can have because what does the patient have to say? What's the family or the caregiver have to say? And again, what did the physician say when you discussed the fact that the medical record didn't support that first level assessment that you did for medical necessity? Bev, we have a question. Okay. Has anyone had success with advantage plans and the two midnight rule? How do you suggest we appeal these if we get denied? I will say, wait until next week. And we will be talking about that. And I'm gonna tell you, there is no slam dunk for this because those Medicare advantage plans are doing everything they can, but there are some helpful hints that we are gonna share with you. Okay. There's one more question here, Bev, but just real quick while you're doing that. Yep. And this one just says, can you speak to whether there are best practice standards for UR nurse MN documentation? And this person stated that they started a new job and the UR RNs copy and paste the entire H&P or most of it into the clinical review screens. And this person raised this as a concern and they have been challenged to provide established documentation standards from a reliable source. Well, guess who's gonna talk about that in just a little bit? Tony is gonna talk about that. You go face, I'm pretty. I am? I didn't know that. Lindsay, she never told me that. I didn't know. We're gonna talk about documentation. We're gonna talk about, and we're gonna talk more about documentation next week. That's gonna be kind of a common theme here as well. But I think you do have a slide about, that really relates to documentation. And maybe it's me. We'll see. I'm kidding, I'm kidding. I think it's you. Okay. And the last question I see here, that what are the guidelines for a utilization review by an RN versus an LPN? Okay. There are no guidelines. And that- No, there are guidelines. No, no, no. She means do you use different guidelines for an RN? Yeah, yeah. We are very biased in that we feel that a registered nurse, because of their additional training, and often if they've had clinical experience as well, is probably the ideal person to do utilization management. I will say that, and somebody had, I believe wrote this, is finding people who can do utilization management. So we are familiar with hospitals that do use LPNs. I will say Texas, I think you still call them LPNs, but I think that sometimes you have to do what you have to do, but our recommendation is that it's a registered nurse. Tony, you want to add anything to that? Well, to answer the question, the LPN would use the same Milliman or Interqual that the RN would use. Usually one set of criteria that your hospital uses. I have absolutely actually been a director where we had both sets of criteria in use, depending on the payer. That's kind of cumbersome, but as far as any demarcation between the RN and the LPN, no, I mean it's whatever criteria you're using. And again, it's not preferable, but if that's what you've got, and we certainly see that as Bev just said. So yes, I mean, no, there should be no difference. Well, and that really does, is there anything else though? I don't want to start if there's another question. No, not yet. Okay, well, here we are at criteria on slide 15. And so that criteria is the foundation to determine if that medical record supports the patient being in the hospital bed that was ordered inpatient or observation service. I kind of throw in outpatient in a bed, but medical necessity criteria is not going to really be, not really going to be something that is, I lost my train of thought. I had my phone on, I forgot to put it on silence. We'll get back to, oh, anyway, the outpatient in a bed is not really a medical necessity criteria. It's just nobody, they don't need anything. So outpatient in a bed, but then here are the, these are the most, the three most familiar criteria sets that we use, Change Healthcare, also known as Interpol, owned by UnitedHealth. We've seen some challenges when UnitedHealth had a downtime, and that was challenged. Some of you who use Interpol may have gone into that. I'm not saying that's right or wrong, it just happened. Some people use, like Tony said, both Interpol and Milliman. They're difficult to use to overcome a denial because the payers seem to use their own slant on them, and they use them in their own ways to determine medical necessity. We'll talk next week about what CMS says about these Medicare Advantage plans and how they need to have their criteria where you have access to it. They then like to make their own understanding or memo about you having access to their criteria really means, but we'll talk more about that. We are seeing Cortex or Exolis being added to the market as an AI product. It's a very interesting product. We're gonna be working with the hospital they use Cortex and I think Interpol, and they're going to be using Cortex in the ED because that's one of the areas that time is of essence. And when you get results in, and we're gonna see how that works for the ED case manager to use that. But many hospitals will say, pick one and go with it. And Tony, like you mentioned, other will use more than one criteria set. We know that when you're bringing new people on board, it is very, very, very challenging to teach them two sets of criteria. So here we go. First poll question, Lindsey is gonna bring this up for us and you're gonna have a chance to answer. Okay, here we go. So you now should all see this question that's up on your screen that asks which medical necessity criteria program do you use? And then there are several options here. You may have to scroll down in your answer choices here to see the remaining list, but MCG, Change Healthcare Interpol, Cortex, MCG and Change Healthcare, and so on and so forth. And at the very end, you'll see every program there is, possibly another program or no program. And if for some reason you are utilizing something that's not listed here, or you would just like to make an additional comment regarding the polling question, you can of course utilize the chat to do so. I'll give you just another couple of seconds here. I see some answers still coming in. That's great. So Lindsey, you can see the question, the answers rather? I can, yep. You're able to see them? Awesome. I can see them as they're coming in and we've gotten some good responses here. We still have a couple people putting in their responses. I'll give it just another second and then I'll end it and share those results so you can see where everybody stands. I think people enjoy these polls because it helps, like I said, Tony and I, but it also helps you see what other people are doing. So I see that Cortex Axillis is scattered in. Well, nobody is using every program, but so the most popular actually is Change Healthcare. Milliman following. A few of you, Gluttonous for Punishment, use them both. And I would also, I would really be, I'd be interested to hear how effective it is when you're doing denials with them. Okay, thank you, Lindsey, so much. Let me see here, okay. Oh, Lindsey, your hint was so great. I did that right quick. Perfect. That was great. Just a reminder, best practice utilization management occurs at the bedside. There is nothing, you know, there's nothing like face-to-face conversation just between two people. And there's nothing like, and that's why FaceTime. I mean, I am a grandmother of 12 and I love being able to FaceTime with my grandchildren. But anyway, enough about that. So go see the patient, see what's going on. Okay, psych hospitals. Let's talk about medical necessity or medically necessary. Two words, and medically necessary is I think the term that's used more now. LUCID, which used to be New Directions Behavioral Health. And I wanna be very, I wanna be very transparent here. I am not a psychiatric nurse. I have never been a psychiatric nurse. I do treat my husband sometimes to explain to him when he's wrong about certain things using some sort of mental manipulation, I'm sure, but that's my extent. But Tonya, have you had some psych experience? As a director of case management, not as a clinician, but yeah, yeah. It's a little bit different. You know, there's different rules and regs and stuff like that. But the case managers, you know, if you go back to those fundamental roles that we talked about, they're still doing those. You know what I mean? It's not different because it's a different clinical area, but there are different regs and things that you've got here on the screen now. Well, if you look at, we're gonna look at the rules and regs regarding utilization management for psych next week also as we look at the acute medical hospital. But I think it is important that you also remember that the Case Management Society of America, CMSA, and the ACMA, the American Case Management Association, they both have standards of care and they don't differentiate your setting. So regardless of what setting you're in, there are standards of practice that are out there. But we do know that the treatment in the psychiatric hospital with your behavioral health patients are different. And so what they say is they begin to talk about healthcare services being rendered by a provider that's exercising prudent clinical judgment. Like that almost should be in ours, our acute care medical hospital as well. And then it describes them consistent with the whole process as defined by the DSM, the Diagnostic and Statistical Manual of Mental Disorders. I need to say that faster. And then just generally accepted standards of practice as defined by credible scientific evidence and peer-reviewed literature and it goes on. That does not happen in the medical necessity explanation that we use in the medical hospital. And that's really kind of unfortunate. Even though it says that credible scientific evidence is important, those medical directors at the payer have high level power over how they interpret things that are to us very evident as scientific evidence. And then clinically appropriate and designed to meet the patient's needs. And then how often are you gonna do it? How long are you gonna do it? Where are you gonna do it? And how long are those services going to last? And then the idea is that when you're looking at medical necessity, the care is considered to be effective to improve symptoms associated with the patient's illness, disease, injury, or deficits in their functioning. We're gonna see some other very interesting things here as well. They talk about being provided at the least restrictive and the most clinically appropriate level of care. And as long as it's safe, effective, and efficient to meet the needs of the patient. So we've seen that before. They're much more descriptive in the second bullet that it needs to be required for reasons other than convenience of the patient, family support system, physician, or other healthcare provider. And they're not a substitute for non-treatment services addressing environmental factors. So that really gives you an idea of what kind of patient really needs to have care provided in your hospital. Now, I'm just gonna say this tough statement, this last one, I think this is, I haven't seen cost discussed like this, not more costly than alternative service or services which are at least as likely to produce equivalent diagnostic or therapeutic results for the patient's illness, disease, or injury. So a little bit different in that whole process as well. Okay, and then the guidelines that you use make the determinations. It's not expected to replace prudent clinical judgment, which CMS has said, even though that does seem to be what we see, not exhaustive, will not cover all potential clinical situations. So this is really where we get into the case-by-case basis. And we'll talk about a case-by-case basis when we're talking about the two midnight rule and then reviewer, how to review the physician or the peer clinical reviewer is gonna review all of the exceptions that are generally accepted standards of good medical practice. So just interesting that you psych people have got some really great verbiage there. And then the last part of your psychiatry, hospital medical necessity slides is that you're looking at the intensity of the services. What was that initial authorization request? And then once you've reached past the authorization approval after your request, then you may have some ongoing things. And so it really, I just think it's very interesting that we need to look at both sides of the coin and there's some interesting things that are there. Okay, let's do another poll question then. We wanna know who you are out there with us today. And Lindsay, boy, you are on it. Absolutely, so this should be up on your screen. I see several of you are already putting your responses here. Thank you so much. And of course it says, if you're a case manager, you're responsible for utilization management only or possible utilization management, case management to other utilization management roles. And then this is, I'm sorry, this is my slides that really should say that is kind of garbled. That second one is, do you do the utilization management integrated into your other roles? So are you doing only utilization management or do you include you in with your other roles? Sorry about that. I didn't mean to interrupt. Discharge plan and care coordination. Right, resource management, exactly. Perfect, and then while I see some of you still putting in your responses here, one additional question came in, Bev, that says, I'm not familiar with outpatient in a bed. Is this something a critical access hospital can bill? It absolutely is something that a critical access hospital can build. We have heard that some EMRs will say- You can't bill for outpatient in a bed. There's no billing. Read the question again. It said, I'm not familiar with, let's see, I'm not familiar with outpatient in a bed. Is this something a critical access hospital can bill? Well, Bill, I thought you said build. Okay, I'm very sorry about that. Oh, I'm sorry. Bill, as in billing financially. Sorry. Okay, well, you can't bill inpatient or outpatient, but you can bill some of the outpatient services that you might do in the bed. That is really up to your compliance department and your finance department, but how they would do that. But you definitely can't bill like inpatient or observation services. Perfect, okay. And then one other additional question before I end this poll and share those results that came in asks, can you address outpatient surgeries being placed in observation right after surgery? What does usual recovery period, six to 23 hours mean? And how do you determine which surgery is six hours versus 23 hours? Well, that is in next week's webinar. Yeah. Those slides are already in there. So Tony said that is one of the most frequent questions she gets. That's correct. That's a hot topic. And I have to tell you while we're just adding up the poll questions, I had ankle surgery. I may have mentioned this in another webinar, but I had ankle surgery and they immediately put ambulatory surgery and observation, which is completely incorrect. And I also didn't bother to tell the surgeon. I figured it wasn't my problem, I'm the patient, not the case manager. But in any case, yeah, we're gonna talk about that next time because I think a lot of you are struggling that's become sort of conventional wisdom all of a sudden that everybody goes into observation. So we'll talk about that. Okay. That was my two cents on that. Yeah. I'm gonna end this poll and share those results here. And then I know several of you will be typing in your questions and there will come a time towards the conclusion or the end of the presentation where there'll be several polls back to back. So just be aware of that. And then we may not address your questions right away from here on out throughout the presentations. Just note that if you are typing a question into the chat or the Q&A, it will be addressed before we conclude today. Well, this is very close and we are seeing a transition. I think probably because of the payers and the challenges with the payers and that case manager at the bedside who incorporates utilization management into the discharge planning and care coordination, the challenge of understanding what each of those payers actually mean. So thank you for sharing that with us. Well, I have to say that if you're a politician, those are not close numbers. They're very far apart. Anyway. That is true. You are on that one, Tony. That is very, very true. So, whoops. I think I went the wrong way. Yeah, you went. Okay, hang on. Here we go. Well, just a minute. Oh gosh, hang on a second. Okay. Now let's go. Okay. So we mentioned this before, the RN case manager performing utilization management for medical necessity. This is a first level review and not a final review. So who would then provide the second level review? And that is the utilization management committee member, your URM committee, or URM, UM committee, according to the conditions of participation, they call it UR as I mentioned, a physician advisor, your physician advisor would need to be members of the UR committee. And we'll talk a little bit, Tony, I'll talk a little bit more about physician advisors. You can have internal, you can have external, you can have a hybrid or you have actually both of those. Okay, so let's talk a little bit more then about this process, the physician provider, not being able to add anything more to be able to show that medical necessity would actually meet the level of care that that doctor ordered. It could have been a, it could have been a patient, they wrote an order for observation service, but the patient doesn't meet that level or they could have been inpatient and the patient doesn't meet inpatient level. So if they can't add anything else, then we as nurses, you are a nurse, you are a case manager. I do wanna say, if you are, if you do UM, you are, we kind of use those back and forth here, but if you're a UM nurse and you use the title case manager, I would suggest that you make certain, and if you're a case management leader, that those people that are using the case management title are actually following the standard of care that is put forward by either CMSA or ACMA, whoever you choose, but a non-physician shouldn't be the one to determine the lack of medical necessity. So I do the first level review, I talk to the physician, that physician doesn't really have anything else to add. Then the physician advisor, I would refer to the physician advisor. We'll go far in depth more on this next week, but they should have a conversation with the attending physician if medical necessity is determined not to be met. So let me just walk you through this. I do the first level review. I cannot see that medical necessity is not met. I hope you will take out of your vocabulary, Tony, this is one of our pet peeves, I can't get them to meet. Well, you're right. I hate that. Or they don't. Your goal is not to get them to meet, your goal is to see if they have medical necessity that's met or not. So don't really go all out on trying to get them to meet, just do what you're supposed to do. So medical necessity is determined through criteria, but it can also be determined on a case-by-case basis. And your physician advisor is going to be the person who determines case-by-case basis. Now, years ago, years ago, when I was a director of probably my second position as a director, not my third position as a director of case management, we had a physician advisor and we would refer a medical record to a physician advisor. And that physician advisor said, oh, they're fragile, they need to be in the hospital. That physician advisor is not right. Fragility is not medical necessity. Now, there may be other things that support that, but that case-by-case review needs to be done another physician, it's a peer-to-peer review. And then payer contracts, which we will be talking more about in the future, they should have verbiage regarding medical necessity criteria, as well as their appeal and their denial process. Okay, so let's talk about what do you do. We're not here, number one, we're not even gonna know who said, always, sometimes, rarely, or never, but Lindsey's gonna put this poll question up about do you always escalate to a physician advisor if you do not find medical necessity after your first level review? We find that some people really think that maybe it's okay just to go to the physician advisor, but maybe there's something else that can be found and we wanna be gracious with our physician advisors and not overextend them. So here we go, question three. That's a tricky question. The answer isn't should you, it's do you. Just a- Still a tricky question. Okay. And I'll tell you why when we're done. Oh, okay, you don't wanna spill the beans? No, because that will alter the responses. That's right, I mean, that's what I meant, yes. Yeah. The question here, I think clarifying this question is asking is it physician advisor or patient's physician? No, let's say you don't find medical necessity after your first level review. So do you just, okay, that I see, I see. Okay, you know what? That's the crux of the question. Okay, thank you, thank you, thank you. Have people already voted, Lindsay? Yeah. I'll go ahead and share with you what they've gotten if you want to explain it from there. Sometimes, okay, okay. Thank you, I do see, Tony, I missed that. I, sometimes it makes sense in my head. Well, and that's a scary place, may I just say that? But- Yes, thank you very much, yes. So I really, I mean, the answer is you would first try to get additional documentation from the physician of record before you would go to the PA, so. You are exactly right. All right, so that's kind of the answer, yeah. Thank you for that. Yes, you were right about that. Any time, I'm here to serve. I hate to say that. I hate it, I know you do. Can you tell we've worked together a very long time? Okay, let's real quickly go over your steps. There's two options. Integrated into the case management role, you have utilization management, or a centralized GM role, and we saw how that breakout is. Regardless of what you're doing, when you redo the medical record, we already talked about seeing the patient. Here is where that's tough for you and nurse that's not at the bedside, and this is where you need to collaborate with the case manager. But also case managers, you're gonna be going into that patient when you do the assessment that I bet Tony's talked with you all about at some point. You need to share that information that you've seen with the utilization management nurses as well. That's not gonna change their ability to determine medical necessity, but it may help if they are the one that's discussing with the physician some information back from the payer. See the patient, interview them. You can incorporate your utilization management criteria into when you're doing the assessment with the patient. It's very easy to do, and then you apply that first level review. And then you're gonna determine, did they meet medical necessity for the status, level of care that's ordered? If they meet, you're gonna document the review in the UM software, not in the medical record. If the patient doesn't meet, you're gonna contact the physician. If there's going to be no additional documentation, contact the physician advisor and explain to the physician advisor the escalation. Excuse me, explain the physician advisor escalation to that physician, the patient's physician. Again, that should not be a surprise to them. It's not like you're reporting them to the sheriff. What you're doing is saying, you know what? My first level review does not indicate that medical necessity is met, but I'm gonna refer to Dr. So-and-so. And then once that's taken care of, you transmit the medical necessity information to the payer if it's required, and then you determine the payer's response. Often this is a forgotten step, and we'll talk about this a little bit more next week, because sometimes you have denial sitting out there and you don't even realize it because we haven't gotten the payer's final response. So only a physician can provide second level review I know if you're in a critical access hospital, you may have a nurse practitioner or physician assistant that may coordinate with you on second level reviews, and that would be something that you would work out through your medical staff bylaws. But the assumption always is that before you go to the physician advisor, you've spoken with the physician that's caring for that patient, and reviewed the medical record. So we talked about care coordination, that throughput process, ensuring that there's transition that goes through the hospital stay. Your UM nurses are relying on you if you don't do UM to do that, you're relying on yourself if you do UM, discharge planning, resource management, the right care at the right time in the right place, and then ensuring care that's unrelated. And there's actually a hint for that. I've never seen anybody use that, we'll be talking about the hospital issued notices of non coverage next week. But there is one that if a doctor orders, let's say a colonoscopy that's unrelated to why the patient's there, a CT unrelated, that would be have to be something that your administration would support where you tell the patient and the doctor, we can do this, but we'll have to build the patient for it because it's not a part of their benefits, because it's not part of the reason that they were admitted. Probably not something you're gonna do, but you never know. Okay, well, let's look at what's going on here as I move to my last slide after this one, finally, Tony. And this is all of the access points of your patients into your hospitals. Well, I don't really mean that, you could maybe relate more access point than these. But the one I do want to talk about is, I don't know if you can see my arrow there, is this one right here. We have a very strong belief, thank you, if you have a transfer center, that you need a utilization management presence there. Doesn't mean they have to be sitting in there, but at some point you need to cover UM when that patient is transferred into your hospital. And let me give you an example of this. I know this is something that I dealt with in my last place of employment, we had a children's hospital as well. And we would get a referral for a patient that is in a, maybe even in a hospital that has a small children's hospital that needs to come to our ICU. And medical necessity in the ICU needs to be evaluated or medical necessity wherever you're putting the patient needs to be evaluated by somebody who is that gatekeeper. It really is all about gatekeeping for this patient. Okay, so now let's talk about the UM role of the case manager who doesn't have assigned UM process. Even though you aren't responsible for utilization management, you need to know the status and level of care each day that's ordered on every one of your patients. You need to understand medical necessity, you need to understand the guidelines and the process, and you need to have an agreement of which case manager, the UF, the case manager on the unit, who's going to communicate with everybody regarding payer regulations, who's going to tell the physician that the payer wants to give a denial and that maybe we need to do a peer-to-peer if that's allowed by our contract. And then you need to collaborate closely with the UM nurses. So yes, they need to collaborate with you, but you need to do that as well. So get a good communication process. It can't be loosey-goosey or you are going to lose days and you're going to lose opportunities. You need to develop relationship regarding specific payer requirements. So if you have one UM nurse that you may be becoming payer instead of a geographic area, what do you need to know about that payer requirement? You need to understand the two midnight rule, even if you're not responsible for UM, and then you need to understand what their roles is. Are they doing admission only? Are they doing concurrent, continued review? Who's going to do the notifications of the different requirements that are there? So wow. Whoa, I'm exhausted. Well, this is a good start. Yeah, and we did get that classic OBS question. And Bev, we decided to hold off till the end on the questions because people were saying, you know, it was too disruptive. So I get that. So there's some questions on outpatient and a bed and all that stuff. So that's good stuff. Okay. So who helps us ensure that we have medical necessity? It's not just us and it's not just the physician, right? It's pretty much everybody on the interdisciplinary care team. So how does that all, oh, I'm sorry, you have to move this. I'm trying to move the slide out of habit. Thank you. So every department in the hospital has some part to play in the UM process. You know, it's like when we've talked about length of stay or even denials for that matter, there really isn't much of anything that we do in case management that isn't impacted by other departments and disciplines. And this is no different from that. So we're going to take a look at some examples. I jotted down some examples of how each of these departments can play a part in the process. So let's, well, this is a different order than what I have, but we can find it. So admitting or registration, let's say, because we have admitting on the other page. So in your admitting office slash registration, whoever's registering the patient, you know, a prevailing theme that I've heard for the last 20 years is that they don't necessarily recheck the patient's information. So address, insurance plan, particularly, and so forth. And when we don't get the right information from registration at the start of the patient's stay, that can cause problems downstream. If we don't notify the right insurance company, if it's a commercial payer, if we don't start our discharge planning with the patient's correct information in mind, downstream problems. Physicians, where are they on here? Okay, over on the left. So you can have an attending physician or a consulting physician or an emergency department doctor. And regardless of, you have to make sure that they have, that they're involved and documenting in the medical record. Because once there's an issue, a concurrent or retrospective denial, well, then, you know, they're going to look at that physician documentation, including the ED doctors as well. Bev mentioned the use of advanced practice staff. So they're the same, really, as your physicians, in the sense that if they're the provider of record, if you work in a hospital where your medical staff bylaws allow your advanced practice staff to admit patients and be the practitioner, excuse me, of record, well, then, again, their documentation is super important. And I mentioned that because if you're finding deficits in physician documentation, then, you know, perhaps somebody needs to re-educate the physicians. And that's particularly true with the two midnight rule, which we will talk about. But they should be documenting their clinical interventions and their care and so on and so forth. Nursing, obviously, plays a part in care coordination, which plays a part in utilization management. They have to move that patient along. They have to get that patient out of bed. They have to do all the things associated with patient flow. Ancillary services, well, we don't always think about them in terms of utilization management. But, again, it comes down sometimes to documentation, particularly for PTOT, lab radiology, radiology, getting things done timely, and so forth. Your payers. Oh, my gosh. How many times, Bev, have we heard, we aren't allowed to see the contracts? And I'm sure we're going to be talking, I think, I mean, I know we're going to be talking about contracts, managed care contracts, on another one of our webinars in this series. But if you've got delays from your payers, that's also a big problem. And we'll talk more about that. Patients and families can be a snag in all of this, too, in terms of getting care at the right time and getting that documentation correct. And then, of course, we have come to realize, whether it's to reduce readmissions to the ED, reduce denials, that we have to have good working relationships with our post-acute providers as well. Because if we don't, we may have issues with the movement of that patient out of the hospital, which can also result in a denial. So you want to just think more broad brushed when you think about UM, and not just, you know, we often just kind of silo us in with the physician and the PA, and it really is bigger than that. So if you think for a moment, if you could think of any other folks, I think we've got everybody there, Bev, that works in the hospital pretty much, but there may be other departments for you all that would be involved. I mean, if you have an outpatient case management department, oh, boy, but most of us don't have that luxury quite yet. Okay. So let's move on to revenue. What is revenue? Well, it's just simply money, and it's part of, well, let me twist that. Utilization is part of revenue, revenue cycle. And, you know, the two things we have, when I say we, case management has been accountable for forever, has been denials and length of stay, both attribute to money. So it's important for us to understand our place in the revenue cycle. And when we say revenue cycle, this is a very fancy definition, but it's really just all the actions that take place that hopefully result in some money coming into the hospital. So series of activities, connecting the services that you render with the methods by which the provider, the hospital, receives compensation for those services. So revenue cycle has lots of parts and pieces to it. And then, you know, if we are properly engaged in the revenue cycle, then we're going to see at least hopefully the right amount of money coming back to the hospital. So utilization management is, again, embedded in the revenue cycle process. So the patient would be placed in a hospital bed. Somebody would verify the payer and notifications. So that gets back to, again, making sure you've got the right info right from the start. Clinical, your clinical review would be transmitted to the payer as required. And remember, Medicare, we don't do that. But we do want to get a review done, even if it is a Medicare patient, because that also can affect things downstream. The care would be provided. The patient is discharged. Coding is completed. The bill is dropped, as we say. And then we might get a full or a partial payment or denial, full denial of payment. So you see where we fit in here. While clinical care is being rendered, we're behind the scenes doing all these other things that impact on revenue cycle. You have to have some measure of business intelligence in order to be an active player and an effective player in the revenue cycle process. So it's not just the business office or the finance department. It's really that whole bigger picture that we just looked at. You may remember, gosh, how many years ago, Bev, where CMS started to talk more about not just cost of care, but also quality. And so they began to say, yeah, a lot of years ago, they're not going to pay for wrong-sided surgery. They're not going to pay for infections. They're not going to pay for things that happened that were caused by the hospital and affected quality of care. So that brought a different focus. I mean, it shouldn't have, but it did bring a different focus on how the care was provided and denial management. Today, we've got all these regulatory issues that impact on how much we get paid. Sometimes we get denials, as we just said, either the full stay or part of the stay. And that really depends on the kind of managed care contract you have, whether days will be carved out and non-paid, like if you have a per diem contract, which we're going to talk about, or you may have reimbursement penalties for some of the other issues, like readmissions and so forth. So utilization management intelligence is something you need to have for competency and part of the revenue cycle. So many of you have asked about criteria. So you have to have a set of criteria that you're using in your hospital. Why? Because those criteria give you the information that tells you whether medical necessity matches to that patient. And that information is based on lots of literature, best practices, and all of that. So there's always references behind the criteria that you're looking at in your software, whatever program you're using, that tells you whether or not that patient is meeting medical necessity. It's not my impression. It's not the doctor's impression. It's whether or not all that evidence in those criteria are being met. So it's not something you want to just kind of guess at. You want to use the criteria, which is evidence-based, to help guide you in making that final determination. And that's why you just don't want to try to make the patient fit or meet, as some people say. You want to use the evidence before you. I think I've used the analogy before about you being an inspector, Clouseau, or any kind of detective looking for all the information, whether it's laboratory, all those other departments we just talked about, all the physician documentation and other clinical evidence that's going to support that medical necessity based on the evidence in the criteria that you're using. So that's why we use that. That's why we pay a lot of money, because it can't be your impression, your idea. There will be occasions on a case-by-case basis, as Bev was just saying, where, yeah, sure, okay, we're not clear. The criteria doesn't match inpatient. However, this patient looks sick, and that's where a case-by-case review might take place. And revenue cycle extends to all the clinical departments. Now, what I always say is we are a cost-avoidance department. We're a cost-avoidance department. We are not adding revenue. We're preventing revenue from going out the door. Okay. So you may remember we've talked about two models. One is the integrated model, where the case manager does the UM, the discharge planning, the care coordination, resource management, and so forth. So let's look first at that. So this is a day in the life of a case manager who's doing all that stuff, including utilization management. And we call this the integrated model. So medical necessity review should be done for any new Medicare patient, traditional or Medicare Advantage patient placed in observation service yesterday, so the next day. Review yesterday's scheduled discharges to confirm that they were discharged. Yeah. I mean, if you expected a patient to go home in the evening and they didn't go, and see, you begin to see how discharge planning and utilization management are very intertwined. And so if you don't have discharge planning as part of your responsibility, as Bev said, you've got to have a really good, active relationship with the person who does. Medical necessity review now of new patients, you're going to start with yesterday. Then you're going to move into any new patients that have come onto your unit. They could be inpatient, observation, or outpatient in a bed. Now, outpatient in a bed simply means that that patient does not meet an inpatient level of care, does not meet observation criteria. But either we can't discharge them, they were social admission or some other thing, that means that that patient needs to stay in that bed. But we're not going to bill for them. They're just going to be in that bed for a period of time. And we'll talk more about that because, as I said earlier, it is starting to become a part of ambulatory surgery in terms of these kinds of patients. So anyway, complete medical necessity review on any patient scheduled for review today. Now, I would say in a perfect world, every patient should be reviewed. Okay. Going on then with the integrated model, if you do rounds, and we surely hope that you have bedside rounds, you should be participating in those bedside rounds with the physician, hopefully, and the rest of the appropriate members of the multidisciplinary team. And that's where you're going to get more information to support your clinical review. Ensure placement of the estimated discharge on the whiteboard, review approvals and denials. So you're going to review any approvals you got, denials. If it's a concurrent denial, then you have to address that however your hospital addresses concurrent denials. And that would, you know, mean to take those steps, whether you're bringing in your PA, whatever, probably would be a good idea to bring in your PA. And then you're collaborating in the afternoon with the rest of the team, ensuring patients with a discharge plan or order for that day may either be discharged or ready for discharge without delays. And we see so much of that, of course. There was a period of time where everybody was focused on, oh, the discharges have to be out by 12 noon. We know that's not realistic, because you may actually save a day by sending a patient out later in the afternoon, let's say, rather than holding them over for the next day. So it's a tricky thing to measure. Okay. And then more on the integrated model, then follow up with the patient and family after rounds. Send required clinical updates to the payers. Discuss payer response with the physician if you need to do that. If the patient is going to be receiving post-acute care services, discuss that transition with them. Provide choice, and here again, discharge planning, choice for any patient transitioning to another level of care or service. Contact any ancillary service with an issue that could delay discharge. Now, one of my favorites has been laboratory tests. Sometimes we wait all morning for test results from the lab, and that slows down a discharge. So if we can highlight the potential discharges for that day and have that blood work prioritized, that can really help with your achievement of an earlier discharge time. And then, of course, always collaborating, because this is absolutely a team effort. Okay. If you are the nurse who's only performing utilization management, Bev, there's a typo there on assignments. Next time. Thank you. Thank you. Yeah, I just noticed that. Assignments for a case manager with UM as their primary focus. So you could be unit-based. You could be payer-based. You could be physician-aligned, not one of our faves. You could be service-lined. That was very big about 15, 20 years ago, the case managers that were service-lined, running all around the hospital with the physicians. Or you could have a hybrid. And we certainly see hybrids. Obviously, the easiest way to do it is to be unit-based. And be physically on the unit, allowing you to attend rounds, and so forth. So there's a lot of pros and cons to each of these. So you have to determine for yourselves which one probably will work best in your organization. So it doesn't matter, really, where you're performing your function. Although we would like to say, we'd like to see you on the unit, not in a back office with a computer. We'd like to see you on the unit, because it allows you to work with the team real time. It allows you to see the patient. It allows you to have an opportunity to attend rounds, as I said. You want care to seem seamless to the staff, to the physicians, and the patients by preventing delays. That's your care coordination piece here, to keep the patient informed, keep the physician informed when there is a delay. And you want to always keep the family and the patient at the forefront of what you're thinking about as you go through your revenue cycle steps. OK. Going on, then, UM only. If you're the nurse only doing utilization management, that's the collaborative model, where we have the three team members. We have the utilization management person. We have the case manager, who's doing discharge planning and care coordination. And then the third rung is the social worker. So if you are doing UM only, then you're going to do some of the same things. You're going to do medical necessity review on your traditional or Medicare Advantage plan patients who were placed in observation yesterday. You're going to review yesterday's scheduled discharges. But again, you've got to have a conversation with the nurse or social worker who's doing the discharge planning. So there is that extra step there when UM is what you do. Medical necessity review of new patients in observation or outpatient in a bed, and a complete medical necessity review on any patient scheduled for review today. And then going on with the collaborative model, you're going to be reviewing your payer approvals or denials that have been approved. You're going to review your payer approvals or denials that have come in, take steps to resolve those. As we said, you have to have, I would certainly follow the policy and procedure of my department. But certainly, you're probably, if you have a concurrent denial, you're going to want to have a conversation with the physician and the PA or somebody, try to overturn that denial with the insurance company real time. Send your clinical reviews and discuss the payer's response with everybody involved that needs to know about that, every member of the case management team. And then, of course, you're collaborating with your staff on an ongoing basis. So when you're just doing UM and you're a little more disconnected or removed from discharge planning and care coordination, you have to make that extra effort to be sure you're communicating, collaborating with everybody else very carefully. It's really an important part of making that kind of a model work properly. OK, 48, yeah. So physician advisor programs, how do you deploy and assign your physician advisor? Again, it's dependent on your department and how you all want to do it. So we can have internal physician advisors. So that physician advisor is working in the hospital. They're physically in the hospital working with the case management staff, the direct care physician providers or advanced practice providers to ensure that medical necessity is met. Or you may be a critical. Many of you are in critical access hospitals. And you may simply not, one, need to have a PA there all the time. Or you just can't. It's just not possible. So you may have an external physician advisor. So this is a group or a company, really, that you contract with to provide medical necessity reviews for denials and appeals, but also real time on a collaborative and concurrent basis. Or you may have a hybrid program. So let's say you can have an internal physician advisor during the week, Monday through Friday. And then you might want to have an outside group covering for the weekends. Or you could have some other combo of that type of thing. OK. Oh, question. We're going to have some sort of music. We should. We should have music? Oh, we should have music, yeah. Oh, I could do my Jeopardy thing. Oh, here she goes. There it is. OK, so this question should now be on their screen. I see lots of you putting in your responses here. Thank you so much for doing that. And just so you know, I've seen several of your questions come in. We are going to hold those just so that we can make sure that we get through the bulk of the material from Bev and Dr. Sesta. And then at the conclusion, we'll go back and make sure that we address any of your questions. And of course, if for some reason we miss a question, please don't hesitate to type that in again so we can make sure that we address all of those. But OK, we've gotten some good responses here. I'm going to go ahead and end this poll and share those results here for you. Oh, nice. Interesting. Well, the bottom one is scary. Yeah. Yeah, wow. OK. I would love to know if those without a PA are many of our critical access hospitals. I'm just wondering. I have seen several comments here that kind of go along with that, that there are, I think, several critical access hospitals on with us. And there was a comment here. I was trying to go back earlier that may address that as well. So I do believe that is probably the case here. Yeah, OK. All right. There is a comment here that says that they're not a critical access hospital. So Kim, I see that you said that. And they don't have a PA, and they're not a critical access hospital. OK, got it. OK, well, good to the percent that does have an internal physician advisor. Yay. OK, so best practice physician advisor roles. So again, depending on your hospital size, depending on what your administration is willing to do and so forth, you can have a part-time or a full-time. What I've worked with a couple of hospitals where they couldn't afford, and maybe didn't even really need a full-time PA. But what they did was they had the PA come in at their peak times. So in other words, when are you most likely to be accessing your PA? It's probably going to be midday, early afternoon would be my guess. So you could have them come in, let's say, for three hours, five days a week, something like that, or maybe four hours, whatever amount of time you've got allocated in the budget. But that's a great way to get at maybe optimizing the amount of time that you have available from a budgetary perspective. If you're big enough, absolutely full-time is the way to go. And you can use them for other things. It's not just UM, of course. It could be district planning and other things like that. So your physician advisor should be trained in UM so they can apply critical thinking for admission status designations. And again, this gets back to the two-midnight rule and how well they might be working with the physicians in the ED regarding that. Now, we've seen it improve over the years about the physician advisors being a specialty group that's trained and so forth. It's not just the retired physician who wants to do a little more, stay a little bit more in the game and all of that. But rather, we're seeing more and more people who pick this as a role that they want to take on. And so we hopefully are seeing PAs more and more educated and trained in this. Support medical necessity, providing a second level review, absolutely. That is something the PA should be doing for you. They can participate in long-stay rounds because they may have some thoughts and suggestions in terms of how to get these patients moving out of the hospital. They should help physicians. I mentioned earlier about physician documentation. And so if you're seeing deficits in documentation or discharge planning needs, the physician advisor can help intervene with the physician on those. So lots of good things that they can do. And we have a few more on slide 51. Lots of new compliance requirements. And some physicians may be more or less familiar with those. And physicians like to hear from other physicians. So the PA is a good choice in terms of doing any kind of education that might be needed. Also, because they understand medical necessity and they understand what needs to be said in terms of the relationship between the hospital and a payer group, they are also in a good position to perform that kind of collaboration. Same thing for the post-acute providers as well. If they're able to round and have those casual conversations, just put the idea, the thought in a physician's mind or a case manager's mind. That can be really helpful. And they can be your liaison to the CMO or the chief of staff or both. And then last for me is documentation, utilization management documentation, which does not, next slide, does not necessarily equate to all of the documentation that we would like to see from you. But what to document. So first of all, when you're doing a clinical review, yes, you want to use your critical thinking skills. But you also want to use the medical record as your reference for finding the documentation, for finding the physician documentation, for finding those laboratory results and radiology reports to support that patient's level of care. Somebody mentioned about cutting and pasting. You do not want to do that. The payer will not want to read all that. You're asking them, essentially, to do the review for you. And that's not what the process and the relationship and your managed care contracts probably say. So if I'm just sending off the whole medical record, I'm saying, OK, payer, you do the review. That's basically what that is. Document agreement or disagreement. They're going to deny. And they're not going to. Right. And they're not going to. And they'll probably deny the stay. Document agreement or disagreement with a concurrent denial. But you're going to put that in your UM software. Or if you don't have UM software, there should be a part in your electronic record that is not discoverable. Meaning if there's a legal action, we don't have to provide that to the lawyer. So that's usually in the quality section of the software, your electronic record. When to document. You want to keep it current. I mean, that's always true, right? Frequency, how often, department policy, the patient's condition, or if the payer is requesting. If you have software that will help you to remember the next review date, that's great. Close each account, again, if you're using software. And mostly, your UM documentation belongs in your case management software, not in the medical record. With some exceptions, like the two midnight rule. OK, Bev, you're up. Hey, I don't know how many questions there are. And maybe we should. A lot. A lot. OK, maybe we should go to, let's go to some questions then. Sure. Are they in the chat, or are they in the? They are, but I have gone through and created a separate document. So I've been trying to capture them as they've come in, so that we can make sure. Absolutely. So I'm happy to kind of start back at the beginning. Yeah, there's two in the Q&A. Did you get those? Because those are good. We can start with the Q&A here, and then I will move over to what I pulled from the chat. So this first question asks, is it appropriate for non-MD secondary reviewer to make a determination? Is MN midnight? Am I assuming? Medical necessity. OK, got it. Speaking from the non-clinician here, so I apologize. Is it appropriate for non-MD secondary reviewer to make a determination that medical necessity is met in case where the primary URN was not able to determine medical necessity? That is a great question. No. Well, here's what I would say. She's saying, can a non-MD make a medical necessity determination? Non-MD, for example. And the only time I would say that's OK is if you can agree, or you understand why that second person, maybe there was something you missed. But I don't think you just roll it through the department until you meet it. Well, a non-MD cannot make that decision. It has to be made by a physician. Well, this is talking to, yeah, but yeah, that's true. But I do think that if you're a new case manager, feel free to escalate to either your supervisor or maybe the person that's doing your orientation, and they may be able to take a look at it and see something you missed. That would be my only thing there. Yeah, so you're saying, Bev, have an intermediary before you go to your physician, advisor, whomever. Yeah. Yeah, that's a good point. OK. OK, and this next question says, should you include your interqual report in the medical record? You don't want to. The medical record is public information that the payer can pull. No, you don't ever want to show that. OK, and this is the comment here that says, sometimes the primary nurse misses the criteria points. And that could happen, and then that's more of a competency issue within the department, I would think. I'm not sure why a primary nurse is doing a clinical review. That would be my question on that question. Same thing, though, the primary you are a reviewer, the first one. Well, we don't know that. And I can, before I put up this polling question, Bev, there are several other questions. So do you want me to? Yeah, let's go ahead. Let's go ahead. I know for the next several slides, we have a couple of other polling questions. So maybe before we do that, we can make sure we have time to address these questions. So this one says, could you discuss or comment on outpatient in bed versus leave in ED status? Are there any pros, cons, or any regulations around that? You want me to take that, Bev? Yeah, go ahead. Yeah, go ahead, Tony. OK, so outpatient in the bed, you would have to set it up in your hospital with a registration code. And it essentially is saying, there is no emergency care that this patient requires. There is no inpatient care or observation level care that this patient requires. So I would assume, if you're in that situation with a patient in the ED, it's a social admission or something, or a family member's dropped off a patient, or whatever it is. And in that situation, if you have the ability to register that patient as an outpatient in a bed, that's just simply a designation. So you know that that bed is occupied with a patient. But you cannot, you know, there's no, you can't bill for that. It's a courtesy to the patient. And that's how that sits. And that's what that means. And I forgot what the rest of the question was. Yeah, I think that's all right. It was just asking pros and cons, or if there are any regulations around that. So I think that was good. And if I could add, you don't want to leave them as an ER patient. Because that counts as time that the patient was seen in the ED. And that's publicly reported, as well as your ED physicians may have some contractual issues about how long they're going to keep the patients in the ED before they turn over, either to discharge or replace them in admission. It's also billing fraud because if you're billing for ED level of care and the patient is not meeting that, then you clearly knew and that would be considered fraud. Perfect. Okay. And then this next question says, we don't have a physician advisor. What would you suggest here? I would suggest that let's go over the rules and regs next week when we talk about what CMS expects. And then based on that, you can talk to your administration about that. Okay. And then let's see, when medical necessity of criteria is not met, but patient will still pass the second midnight, should a physician advisor be utilized or would it be appropriate to have a supervisor or subject matter expert to make the call if the medical necessity is met? You know what? We're going to talk about that pretty hot and heavy next week. So let's go for that then. Okay. Perfect. Okay. It says, does CMS require a discharge plan on every patient for inpatient and observation? No. Interesting. Yeah, they tried to. Yeah, they tried. It was in the proposed rules for discharge planning, but it didn't happen. So you do not have to. However, a lot of OBS patients need follow-up care. So, you know, I do feel that we need to assess them the same way that we would an inpatient. I mean, but it's not a regulation. It's not a requirement, but many of them will need some discharge planning, but you're not required to do it. Okay. And then can a patient be charged for observation hours and a daily bed charge? Well, that's incorporated into the OBS rate. Yeah. Observation hours actually does not include a bed charge, I don't believe, but that's a finance question. I'm sorry. Yeah. Yep. Okay. And let's see. I think this is more of just a comment here, but it says we are a small critical access hospital with only three attending MDs who this person rounds with every day. I have a good rapport with these MDs as I make rounds with them daily. If I tell them that medical necessity is not met and the payer source of the patient, they typically give me a verbal order to change the level of care. And typically these are patients being changed from inpatient to observation level of care. Well, that really goes, unfortunately, unfortunately, Tony, I know you're getting ready to say it goes against the conditions. Well, we're going to talk about that next week. And I am writing a note to myself too, that we need to really specifically address the critical access hospital issue because we get that, we understand that we're actually, I think in the process, getting ready to work with another one ourselves. And we understand that you are working the best you can. And so we're going to talk about how we can work around that. Well, I mean, at the same time, you can't just back a patient out regardless of whether you're a critical access hospital, I don't believe if it's a Medicare patient, you have to go through the condition code 44 process. So I'm thinking that's the essence of the question, but I'm not sure. Well, and I think we will talk about how you could address that. I don't mean get around and not do it. I just mean, how would you approach that if this doctor said this? So. Okay. And then I think the final question that I see here is when a patient is admitted as observation, but UM review reveals inpatient medical necessity, how much to midnight documentation should we see in the provider note versus just in the order? Oh, you're going to see that next week on a slide. I told them, I said, you're going to have a good group. Absolutely. Okay. I think that's the last question that I see here. Well, let's just do, we've got a couple of minutes here. So let's go ahead and hang on a second here. I'm trying to get my, okay, here we go. Okay. While you're getting that question up, I'll read it, Lindsay, if that's okay. Oh, you've got it. Well, which member of the multidisciplinary care team is the only one who should be allowed to make a final determination that the patient's stay is not medically necessary. The staff nurse, the case manager, the RN and the insurance company, or a physician advisor or a member of the UR committee. Well, that kind of goes to my comments a few minutes ago, so they should all get this right. And I see lots of the same answer coming in here. So I'm hoping so. Excellent. A couple of seconds here. Yeah. Yeah. Okay. Here we go. All right. Yay. As we would say in Oklahoma. Well, that just shows you what an excellent teacher you are, Bev. You know, I'm getting nervous. While we're moving on to the next poll question or the next question, I will tell you, you know, Tony's from New York, I'm from Oklahoma. And so she always says that, oh, hush. She always says that I'm a little bit country, and she's a little bit rock and roll. So there you go. Yeah. Well, okay. Talk about a non sequitur. Okay. Oh, dear. Thank goodness we're almost done. Which access points should have some form of UM process? So when you look at all of those, is it all of them, none of them, or one of those? Oh, they're going to get this right. I know they are. I think they are too. Again, I see lots of the same answer coming in here. Yeah. Yeah. Excellent. Perfect. There's that result. Yeah. You guys are good. I'm not getting any of the little clapping little emojis or whatever. I'm a little sad about that. Okay. Oh, there it is. Thank you. Whoever does that, thank you. I love it. So Tony, talking about that, I would have been very disappointed. What's case management? Oh, my God, a heart. Well, we love you too. Which of these is passive? Oh, I think that's the wrong question here. Let's see here. I think these might be out of order here. Oh, okay. You might, if you wouldn't mind typing those into the chat here for us for this question, which case management term is considered passive? You can just type in A, B, C, or D. Yeah. I mean, I think everybody knows. Yep. Everybody's typing in A. All right. We'll let that one go. Oh, they love it. They love it. Okay. All right. Thank you. Okay. Let's see here. Okay. Is this the one we're ready for then? Let's see. Did I mess something up here? I don't think so. I think that maybe these questions just kind of got out of order here, so I'm not sure here. Let's relaunch. Which one do you have? Just put yours up. Okay. So if you agree that a patient doesn't meet medical necessity, where should that be documented? I think we did cover that a couple of times. Let's see. Just a couple of different responses here, but we'll give it another second here. While y'all are doing that, I see a comment here that says the problem that we have is the ED, MD, placing them in the inappropriate level of care. That isn't always communicated to the accepting or attending MD. So upon the moment that they're in the appropriate level of care, so upon the morning rounds, it is communicated and the MD agrees the level of care should be changed. Well, that's why you have to have some kind of utilization presence in the ED for that exact reason, among other things. But you can't not have case management in the ED anymore. Those two negatives I know, but you really have to interface with those ED physicians to prevent that from happening. Otherwise, yeah, it's going to keep happening. Okay. And if you have case management in the ED Monday through Friday, eight to four, you'll have that problem. Yeah, exactly. Okay. So I would just say that in the progress notes, you don't want to admit that you didn't meet medical necessity. That just sets you up with the insurance company if they pull that medical record. And then you've already just said, okay, give us a denial. Let them figure that out themselves. Asking the physician to document it as an order needs to be about a part of that condition code 44 process that you were talking about, Tony, that there's a whole process that we will go through that are covered in the conditions of participation. So there may be some qualifying factors. We'll talk about that, but it's not just arbitrarily. Please change that. Okay. We talked a little bit about this when we talked about each of the role for each of you, whether you're doing, you are, and when we say only you are, we don't mean that derogatory at all because you've got a larger patient load. You've got the challenges of the world on your shoulders. But whether you are doing, you are alone, or if you're incorporating it in, which patient should be your priorities? So traditional Medicare patient that's in OBS, Medicare patient in OBS, all inpatients, all OBS patients, A&B or A&D. Or EIEIO. That's right. Thank you. DINGO. My gosh. Hurry and answer or she will be screaming. We appreciate the entertainment. Okay. We're kind of, we've gotten some questions all over the place here. So go ahead. Priority would be your key word. Priority. Yeah. And we're going to talk about this. We, we, I almost let this out because we just barely hit on it. But what we want to do when your patients are in an observation service setting in their traditional Medicare or their Medicare Advantage, what you really want to do is make them your priority because you want to either get them discharged or you want to get them moved into inpatient. You really don't want to keep them in observation service if you can help it. CMS says it should be rare that patients are in observation service longer than 24 hours. I know we used to use the term 23 hours and that's kind of gone by the wayside. Definitely. All your patients are a priority and certainly all observation service patients, but the Medicare patients are the ones that are probably or most likely to require skilled nursing facility. You want to get them moved into inpatient as soon as possible. And they might only be here for two more days. And you'd really like to bill the patient as inpatient for a couple of days rather than just one day. So we will definitely talk more about that. So A and B is what I would have selected. But then you know what, I just have to run. I would say all my answer, Beth, be it right or wrong would be all observation patients, frankly. Well, you're right. But the most urgent one is that Medicare one that you could move to inpatient. I see what you're saying. They met it. So right after that would be other odds. You're right. Yeah, yeah. I gotcha. One more last question. And I only put the question here on that portion of the poll that you stopped on your screen. But this says the physician documentation in the medical record of a traditional Medicare patient does not meet medical necessity for the inpatient order based on your first level review. And then what should be your next step? Contact the physician advisor. Discuss your first level review findings with the physician. Write an order for observation service. Or ask a physician to write an order for observation service. I know it's hard to see the full answer there and those options. They might have to look back at the slide there. So we got most people selecting a similar answer here. Okay, I'll go ahead and end that and share that result. Okay. And that's exactly right. What we would encourage you to do is not jump to the physician advisor first, but to discuss that with the physician. My first level review, I don't see medical necessity here. Is there anything else you could add? I see that there's this on the x-ray, that sort of thing. For them to write an order for observation service would be done by the physician advisor after he or she has discussed the case with the physician provider of care with that patient. Wow, you guys have been great. We've covered a lot. And boy, did we appreciate your involvement. We've given you a couple of resource slides. Thank you. The one thing, I have this on my whiteboard in my office here. Keypro, you all have Keypro, but Keypro was going to be called Accentra, I guess, A-C-E-N-T-R-A this fall. You know, everybody has to change their names periodically. Yeah, I just got used to Keypro and now they're changing it. I know, I know. We have a long time in Keypro. Oh, it's just wrong. But there are a lot of places that there's a lot of good information. And then here are some physician advisor resources. If they would choose to be a member of one of these, there's a lot of education that goes along with this. These are really, really good resources. Yeah, they really are. Thank you so much. Yes, well, thank you all so much. Thank you. Well, we've just in the nick of time. That's amazing. That's perfect. And I did go ahead and post just some final comments there for you all in the chat just as a reminder that you will receive a link to the recording of today's session. Just note that that email that you're going to receive tomorrow morning will come from educationnoreplyatzoom.us. And so because it comes from that Zoom email, those do very often seem to get caught up in your spam, quarantine, possibly a junk folder. So if you don't see it in your inbox in the morning, go ahead and check those additional folders. And then if it's still not there for any reason and you would just like to go back and access the recording of today's session, we do record these as on demand, meaning that you can use the same Zoom link to access the recording that you're also using to join us for today's live session. And then also just note that if you are planning to join us for each session in this series, there is a separate Zoom link for each session. So if you're joining us as a member of the Georgia Hospital Association, you will receive a link for each session the day before the live session takes place. And if you're joining us as a partner with another state hospital association, you'll be receiving that information from your contact at your hospital association as well. And then also included in that email tomorrow morning will be a link to the slides that were presented here today. I did go ahead and provide that link there for you in the chat to have as a resource. And you do see on this screen here that Bev and Dr. Sesta's contact information. I know that they would be happy to answer any additional questions that you have. You can reach out to them directly or you can always reach us at education at gha.org. And we are more than happy to pass along any questions or concerns to our presenters today. And I just see lots of comments here in the chat saying that this was a great experience, so informative, and just thanking you for the great information. And then one question here I see asking if there are CEs with each of these sessions. If you're joining us as a member of the Georgia Hospital Association, we are providing ACHE and the Nursing Home Administrator CEs for this series. And you will receive a survey at the conclusion of the full series that will direct you to a survey to complete that will then provide a certificate of attendance. And then again, if you're joining us as a member of a partner state hospital association, please reach out to your contact there at that hospital association to obtain any information regarding CEs. Okay, I don't think I see any other questions at this time. But again, if we can be of further assistance before we see you all back with us next week, you can reach us at education at gha.org. And we just thank you so much for your wonderful engagement with us today and all of your wonderful questions. And of course, thank you so much to our speakers. We so enjoyed having you with us today and we look forward to having you all back with us next week. And I hope you have a wonderful day and a wonderful weekend. Thank you so much. Thank you. Bye everybody.

Bev Cunningham

Dr. Tony Sesta

utilization management

healthcare

medical necessity

patient care levels

case managers

physicians

medical criteria

physician advisors

psychiatric hospitals

clinical judgment

DSM criteria

physician reviews

payer documentation