with Part Two. Bev Cunningham has been a partner and consultant with Case Management Concepts, LLC, since its conception. 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 manager in the revenue cycle, compliance for case management departments, the role of the physician advisor, and effective denials and appeal management. And 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. Her research has included two funded studies measuring the effects of a case management model on congestive heart failure in fractured hip patient populations, with measures of patient satisfaction, quality of life, and short and long-term clinical perceptions and outcomes. Thank you both so much for being back here with us. We invite you to go ahead and kick us off for part two. Well, good morning, everyone. This is Bev Cunningham. We are so happy that you're here with us today. And if you joined us last week, welcome back. We are going to be talking about rules and regulations that impact utilization management. This may be part of the stuff that drives us nuts, but Tony's here with me. Tony, we're going to be nuts together today. Yep, we will be crazy, but we love rules and regulations, don't we, Bev? I mean, they tell us what to do. It's so easy. Yeah, it would be easy if CMS would just be clear about what they meant about things, like the two midnight rule when they started, and then they've had to redo and redo and talk to us again. And we're going to be talking about some of those things today. So just a quick refresher about, you know, the foundation we discussed last week is that case management has four basic roles and utilization management really was the foundation of the case management process as we know it now, resource management, and that's really just looking at the resources that are provided. Those are addressed just a little bit in the conditions of participation, utilization review, care coordination as we move that patient through our facility, and then discharge and transition planning and helping them move from one unit to the other and then move on to the next level of care. Just a reminder on the definitions, when we talk about UR and UM, utilization review and utilization management. And if you had the opportunity to be with us last week or hear us last week, you will know that we, or at least me, at least I do this for sure, is I do use them interchangeably and then the term medical necessity. But the idea when we're looking at what these three terms mean is that we're going to look at the medical necessity, we're going to look at the appropriateness of the services that are provided or proposed to be provided to a beneficiary. That would be a beneficiary of Medicare, a beneficiary or a member of a particular payer. And so when we want to have that foundation that that patient should be in our hospital. Our process, utilization review back in the day when you had somebody kind of sitting in the corner, maybe nobody's as old as we are Tony to remember this, when that person would sit in the corner with the clipboard kind of look lost and everybody thought, you know, wow, if that nurse would just quit doing what she's or he is doing and help us out here on the unit, things would be much better. But there were some really funky rules and regulations even back then that they were addressing. But utilization management, the term we live with today is something that's active and operational. So when you do you are, you're auditing physician documentation. We are not the judge and we are not the jury about what the physician document or doesn't document. Although I'm sure you have some very strong opinions about some physician documentation that you read. But utilization management is taking that you are a step further and really doing something about it. And we're gonna talk today about the processes that we're going to follow when we do something about that review once we have seen it and we've done what we call our first level review. And then medical necessity probably best described is just doing what the patient requires at a specific point in time, neither more nor less than what they need to have done right then. Okay, but here we are to the rules and regulations and probably we didn't even get all of these here on this slide. But I do wanna give you, you all have some great questions last week. And I had said, and Tony had said, well, we'll get to that one when we talk about rules and regs next week, or we'll get to that in webinar three, when we talk about denials and appeals. So I just wanted to give you a little bit of a picture of where we're heading. So today, rules and regs, next week, denials and appeals. And then webinar four, we really saved to do some case studies that you can work on, but also to pick up some of the things that we were not able to touch on in the first three webinars. And so I will tell you now that in webinar four, we are gonna talk about your payer contracts and your role in the payer contracts as it relates to medical necessity. And then we're gonna talk about physician collaboration as well. We'll hit on those a little bit in each of our webinars, but we wanna go a little bit more in depth. And then we're gonna talk about some roles also. Tony, I know this is one of your favorite roles, but that's that clerical staff that supports the case manager and the social worker out on the floor. Clerical staff can support in each of those four roles that we talked about, but we will talk in webinar four about that clerical staff as it's related to utilization management. And then we'll also talk about the role of an appeals coordinator as well. So that's kind of where we're headed. And so we'll just get to moving here. Compliance is shared. This is anything that is non-compliant is not always case management's fault. And I will say probably rarely is it case management's fault because it is a shared process. And so when we talk about some of the different rules and regulations we're going to talk about today, there may be that patient access has a part in that. It may be that finance has a part in it. Certainly physicians, you that are out there on the units working as case management staff have a role in it. If you're a leader, you have a role in it as well. And then we know that probably most of you now have advanced practice practitioners that are gonna be a part of it. Nursing is involved in it as well as all of our ancillary services. We talked about utilization management beginning at the access point for your facility. We talked about that last week, but compliance begins at that very same as well, that same place as well. And so when you look at the very top of, when you look at compliance and go straight up to ED, actually, I can just kind of put my pointer there. That's really the front door to your hospital. Other people walk in what is said to be the front door, but your patients, a bulk of your patients do come in through the ED, but they also come in through a variety of other places as well. And so we know that many of these places, if a patient's going to be placed into the hospital, whether they're gonna be outpatient in a bed, whether they're gonna be inpatient, whether they're going to be observation service, that determination of that initial order is going to have to be written as that patient comes into your facility. And so that's where we begin to see case managers really taking an active role in compliance and working with the physicians. Now, we would love to say that physicians love all those rules and regs. They love to midnight rule, but that's not true. Some of us don't even like it, but it is what it is. And so here we are. And so we can influence and really talk to the physician as well as that physician advisor being a very important part of the process. Now, we just talked about the ED. So let's do a poll question, and Lindsey's gonna put that up. But the question is, do you have a case manager in the ED who applies utilization management criteria? So yes or no. And we'll let you- Perfect, I see several of you responding there. We'll give you just a second. And then for those of you who may have dismissed our introductory comments, we will have several of these polling questions throughout the webinar today. And we will also pause to address any questions that you have for our speakers during that time. So if you do have any questions as we go throughout, please go ahead and we type in those into the Q&A option found there at the bottom of your Zoom window. Or if for some reason you don't see that, we encourage you to utilize the chat for those questions and just for engagement with us today if you have additional comments as we do these polling questions as well. Okay, we've gotten a good response here. Okay. Wow. Actually, that's kind of surprising to me. What about you, Tony? Yeah, I'm very surprised. That's crazy. That's crazy talk. Wow. Well, one- Go ahead, I'm sorry. What do you want to say? No, no, I was just gonna say, I don't know what to say except that that's a problem, you know, the two midnight rule, lots of reasons why that's a problem. So you go ahead. Well, you know, the one thing that we do know for certain is that it is really difficult to apply utilization management criteria when the patient is in the ED because we don't have all our results back. Maybe your physicians are really trying to get your patient through the ED quickly and move them on to the next level of care. But Tony, like you mentioned, that guidance of where the patient needs to be in whether observation service or inpatient or even outpatient in a bed, if there is no medical necessity, but there really is no alternative for them, that needs to be guided by a case manager who's working through that process and talking with the physician and even the hospitalist or whoever's gonna admit. Go ahead. No, there's been a couple of comments, interesting comments. One was we don't staff because of, I'm just trying to pull that up, because of, you know, budgetary limitations. So to that, I would say you really have to make the ED somewhat of a priority. I mean, this is a whole different conversation, obviously, but you need to think of the ED as another unit in the hospital, not as something we can't deal with because you're gonna be out of compliance. And also, you're going to not catch all those inappropriate or unnecessary admissions. And the second comment was, somebody goes down there on call, then you're not addressing discharging from the ED, you're not addressing throughput in the ED. So I get the budgetary issue, but I think if that was a case management leader making that comment, that you might need to go back and revisit that or talk to your boss about it, because as we go through today in particular, you'll see, and last week too, we talked about a lot of the compliance issues and so much of that now starts in the ED as well as discharge planning in the ED. So that's my two cents on that, but I appreciate those, I'm trying to find those comments. Oh, here, typically related to staffing. We have nurses review, they have a concern, they will contact the case manager on call. We just don't have a case manager in the ED and I'm guessing these folks don't have a social worker in the ED either. Okay, we train the ED nurses to know the rules. Okay. You know, I would say sometimes people don't know what they don't know. And so if, and Tony and I are both nurses, so we get this, but if you're busy in the ED and you have a lot going on, you're going to go through the path of least resistance. And oftentimes the path of least resistance is something you're not familiar with. Oh my gosh, I did end up with a preposition and there we go. But that is, the idea is that if you're on call, sometimes they just don't know that they need to call you. I will tell you, and I jotted this down because we'll talk a little bit about this next week with denials and appeals. If you need to support a case manager because of budgetary reasons in the ED, you can always look at how many condition code 44s you did, how many provider liables or condition code 121s you did. And that, and if they came through the ED, you will see that that might be something that can speak when you're talking about denials, that can speak very powerfully to you. And social admissions. I mean, I was just gonna say in social admissions, there's all that stuff that you can put dollars to that would pay for that position. Bev, should I just read this one last comment? It's really a comment. No, go ahead. When I started this job 11 years ago, I was informed prior to admission during my working hours of a potential admit, then I would discuss with the admitting MD level of care. Over the years, that process faded away and it was felt that it wasn't necessary. I disagree. Excellent point. We do have ER resource for discharge planning and pre-admission review, if no discharge plan or for ED patient, okay. Hospitals with UM and ED, what hours do they work? What provides best coverage? We have a small volume of acute observations, two to three per month. So our supervisor on call has access to intercalling is consulted if needed. Quick and easy cost benefit analysis would make the case. That's what I was trying to say. In terms of ED hours of coverage, I don't wanna go off on that tangent. Emily, would you at the end, or if you already have my email address, I would be happy to give you the skinny on ED staffing coverage. And I will happily answer your question. Okay, I just don't wanna go off on an ED tangent because I can talk about the ED for an hour. Well, you know what we might do? Let's see how webinar four looks and we might even be able to talk just about the ED case manager in relation to utilization management. You know, we do have one hospital, if that sounds like a deal. We do have one hospital that is using Exolis. I'm trying to think of their other name. I can't remember it right this moment, but nevertheless, they are using it in the ED because if you have a very busy ED, keeping up with lab results, and those are the kinds of things Exolis uses AI to determine the number of points that you get a score. And that helps to determine if you're observation service or inpatient. And so that will support that case manager in the ED. So that's something that we're trying out. We'll see how that works out. Yeah, if we can fit the ED, and it only has to be like, I have some slides, you know, three slides maybe. If we can pluck that into webinar four for Emily and everybody else who may be asking the same question, I think that'd be great, Bev. Did you just say pluck? What did I say? I mean, you said put that in. I thought, no, I'm just joking. Did you? I didn't know you said put that in. She did say that. What did I say? Oh, I did? She did say pluck. Oh, Lord, oh, Lord. Well, let me tell you something. Two days ago, Bev had a hailstorm in Oklahoma. Well, guess what's happening right here, right now in New York as we speak. Did I send it to you? Yeah, I don't know if you guys could hear the thunder on my microphone, but it's like right over us right now. So sorry about that. Anyway, pluck, put. Okay, here we are. And Terry says, please add the EDUR into the fourth series. Yep, yep, yep, you got it, you got it. Will do, will do. Okay, well, here we are, the dreaded two midnight rules. So, here we are 11 years later. It started, you know, the federal fiscal year is October 1st to September 30th every year. October 1st, 2013, we could not believe we saw the proposed rules. We could not believe that this was going to go into effect. And it really only applied to traditional Medicare patients. So, 11 years later, here we are. And beginning this year, January 1st, they didn't do this according to their federal fiscal year. The two midnight rule began to applying, began applying to both traditional Medicare patients and Medicare Advantage plan patients. And so next week, we will also talk about these denials and maybe what some other hospitals are doing as they try to work through the Medicare Advantage plan. Not only was it the two midnight rule, but it was also that Medicare Advantage plans have to follow the inpatient only list. And so, they've been busy. They've been busy working to see what they can get around. And I know that you've probably had some challenges and other people. So, we're gonna pass along. This is a very, very new process, but we will talk through the appeals on that particular situation. So, the two midnight rule says that, and you all, I know that you all have heard this, maybe if you're a new case manager, you haven't, but inpatient admissions are generally gonna be payable under Part A for Medicare patients. Traditional Medicare patients fall under Part A. That's how that pays for inpatient as well as a few other things. If the admitting practitioner expected the patient to require a hospital stay that crossed two midnights. I want to make certain that everybody knows because this is a quote from CMS. It doesn't say that you have to be in there two midnights. It says that the doctor has to expect that the patient will cross the two midnights and the medical record supports that reasonable expectation. And then it's not, that payment is generally not appropriate if the stays aren't going to span at least two midnights. And we'll talk about some exceptions to that rule as we get, as we work our way through this. All of you, all y'all on here, you are on the two midnight rule. It applies to everyone, critical access hospitals, long-term hospitals, psychiatric hospitals are also included. So payment is contingent on us following that two midnight rule regulation. If you've been on a call with the QIO who's talking to you about some sorts of stays that they want to deny, in their mind, in their mind, and remember they're getting paid a bonus on things that they can deny. I don't know how that bonus works. So don't take my word as gospel exactly how that works. But nevertheless, that payment is contingent on that two midnight rule regulation. The challenge is, and I will say, this is a big challenge, is that it's their interpretation versus our interpretation of it. Because like Tony, you said, oh, it should be easy, but it's not easy because the two midnight rule isn't easy in itself. So what is a physician supposed to document? Okay, I expect this patient's gonna be inpatient at least two midnights. And then why is that patient in there? It has to be medically reasonable and necessary. Medicare CMS from the very start said, this is not according to Interqual, this is not according to Milliman Care Guidelines, it's not according to any other medical necessity criteria program. It is medically reasonable and necessary care that's documented by the physician and that physician should also discuss the discharge plan. Now, here we come to this square, it's a rectangle in the upper left portion of this slide that says it's all about gatekeeping in a sense of urgency. And so these are the two key components when you are dealing with the two midnight rule. You've got to get a hold of them as they enter your facility. They may be coming in through the transfer center and we know that if it's a smaller hospital, and I say this in all respect, I've worked in small hospitals, I've worked in large hospitals, but I do remember working in my last hospital where we had a children's hospital and a hospital would call and they need to transfer a pediatric patient for a higher level of care because they need ICU. Well, they actually might not need ICU in our facility, they might need some intermediate care depending on the levels of care that you offer, but that's why we have to gatekeep for our patients as our patients come in. We have to gatekeep that surgery schedule, we have to gatekeep the ED, we have to gatekeep the physician office who wants to send their patient over to be admitted. So it really is all about gatekeeping and then it's all about a sense of urgency. And I know that, you know, I can remember as an ICU nurse, that's my background, I loved it if I was working nights and I came in and every bed was full and I was tired and I knew we weren't gonna get any admissions probably. And then there were other nights I would come in and I would be saying, oh, you know, I don't want anybody to have a rep, but if there's gonna one happen, I'm gonna let it come to our hospital because I am ready to go. We have to have a sense of urgency regardless how we feel when we come in, regardless of how your children acted the night before or your spouse or your significant other or anyone else, we have to have a sense of urgency. So you're gonna hear that discussed several times. So when we think about observation service then in the two midnight rule, that patient is just gonna be expected to be there less than two midnights. That is their best positions, best guess. Sometimes we have to help them as they're working through that. But if a patient has been in observation service after midnight, that should be our priority. If that patient needs to be admitted, let's get them admitted, put into inpatient, make sure that physician documents why or let's discharge them or let's keep them in observation service. However, that should be not very often. And we certainly don't want patients languishing in observation service. And so- Love the word languishing. I love to use that, it happens so. And we won't do a contest on here of who has the patient in the longest stay for inpatient or the longest stay for observation service, but you know who you are, you might win. So when physicians- I think I would win, Beth. Oh, you probably would. I think I would win for inpatient, yeah, I do. New York might win for sure, yes. So when physicians- Should I say, can I say how long- Yes, please say. For an inpatient, three and a half years. Okay, if anybody's longer than Tony, please put your number in the chat and we'll address it during the next poll question. Oh, look, look. Somebody's going, oh, yes, okay. Well, and then I became the vice president there and then that patient was discharged. So I just want to say that too. Did you take them home? Actually, they went back to South America where they had- Oh, and there's a clap for you, okay. So when the physicians are rounding, that is the time to talk about it, but let's talk to those of you that are doing utilization review, that's your primary focus. And those case managers that are out on the units that are not, that don't have the primary focus of utilization review, it is incumbent on you all to talk to each other because that is where the sense of urgency comes. You want to be able to put that patient as an inpatient and let them, and let you get paid for the inpatient rate if indeed that is appropriate. Okay, so still thinking about the gatekeeping and the sense of urgency. If they're an inpatient, we already talked about this, but I just don't think we can say it too many times, documentation and many people have developed an order that says, I expect this patient to be here at least two midnights in your EMR. And again, it has to be supported. The only exception is inpatient only procedures. And just a reminder, inpatient only procedures are now included in the responsibility of the two midnight rule for Medicare Advantage patients. Well, not with the two midnight rule, inpatient only procedures are a responsibility of the Medicare Advantage plans to acknowledge. Okay, so let's talk about then what happens if our patient expected to be two midnights, but didn't stay that long. And there even, Medicare did say this, I honestly don't think, Tony, that we've seen any of these. They have said expected one day stays may be acceptable, depends on the judgment of the physician. It might be that there's a particular surgical procedure that really needs inpatient care, even though we totally understand that our patients get the same care regardless of their status. But they may say, this particular procedure, it's an overnight procedure, they are gonna stay overnight, they're gonna go home the next day, but they do require inpatient care and they have to be able to support that in their documentation. It's a case-by-case basis, CMS expects these to be rare and these admissions will be monitored and reviewed if appropriate. Well, let's talk about the- And if they see enough of them, if they see a pattern, that's what's gonna trigger that audit. So it's not, it shouldn't be standard practice yet. One would hope, wouldn't one? Yes. Okay, well, let's talk about some exceptions then because these are really, really important. One day stay due to unforeseen circumstances after the patient has documented that I expected this patient would be two midnights, but they didn't stay. CMS is very generous. If you die after one midnight, they'll say, okay, we'll pay. If you're being transferred, they will pay. If the patient is leaving against medical advice, they will pay, but only if it's been coded as leaving against medical device, medical advice. So what we have seen is that a patient wants to leave and they talk the doctor into discharging him and the doctor said, well, I don't really agree with this, but I'll discharge you. And they don't write discharge against medical advice in the record. It's not coded that way. So it does not become an exception to midnight rule. We have heard some old wives tales that home care will not provide home care if the patient leaves against medical advice. They can't get pharmacy. They can't get DME. And we've never heard that to be the case. So encourage your physicians if the patient's going AMA to write that AMA order. Unforeseen recovery, and we'll talk just a minute about that. Election of hospice care and then new onset mechanical ventilation. Let me give you an example. This came out as a memorandum of some sort several years ago where a patient, maybe an overdose, would be ventilated in the ICU. Then they'd wake up the next morning. They'd be fine. They'd be off the ventilator and they would be able to go home and follow up with outpatient treatment. That is an exception to the two midnight rule. So any unforeseen interruptions in care, any changes in the expectation has to be documented. So let's talk about if the patient gets well sooner than the physician expected. That has to be documented. And the direction has been to us not, oh my goodness, this patient did so well, I didn't even expect that at all. That really does not support unforeseen recovery because the question will be, well, why didn't you put them in observation service in the first place? But what a doctor might wanna write is, I fully expected that this patient would take at least two midnights because of blah, blah, blah, whatever it is. And much to my surprise, I do like that term, much to my surprise, this patient recovered more quickly than they ever have before. Maybe this is a patient you've seen before. So the idea is that your medical record is a story of what's going on with that patient. And that is so important that physicians realize they have to tell the story. It's not just a cut and paste from one day to the next. It is, let us see the story. And again, Tony, just like you said, these claims may be considered appropriate for hospital inpatient payment. They also may not, might be something you have to fight. Okay, now, what is your responsibility? This we've talked about before. So we're just gonna touch base on this. Any traditional Medicare or Medicare Advantage observation service patient, after one midnight, you've gotta reassess them and collaborate with the physician. You are nurses. If you're separate, you and the case managers, your leaders need to determine who's gonna talk to that physician. How is the communication going to occur? Because one thing that we've heard when we work with hospitals that have you are separately is that the you are nurse will send an email to the case manager on the unit. And in the morning, the case manager on the unit in most likely will not see that email. So there has to be some sort of process where that case manager on the unit knows what's going on with that patient because then you're gonna have to transition that patient, either inpatient. And that may be very simple. There may be some results that came in overnight that automatically transition that patient to inpatient. But getting that patient discharged is very critical. And the one thing that we do know is that observation service patients require a lot of discharge planning. I think, Tony, we've seen that over the past several years. And when that first started happening, it really surprised us. But there is some effort to occur to get a patient discharged. And then if observation is going to continue, certainly discharging as soon as appropriate. And so really having that patient on your radar. That's not to say, because we talked about this last week, that's not to say that every other observation patient is not important. They absolutely are. But if you're going to work with your Medicare and your Medicare Advantage plans, this has to be a sense of urgency. This just is a different picture of looking at the transition process where if they're gonna be inpatient, you get an inpatient order. If they're observation service, understand why they need to stay in observation service. You might be able to discharge them if there's additional testing that could be done as an outpatient. Certainly you want to include your physician advisor in this. And again, just like I said recently, or at the last slide, if outpatient is not possible, keep monitoring that patient and even monitor them throughout the day. And then your discharge resources, just as I mentioned, social worker, and that clerical associate we want to include. They are so critical in your staffing to really support your RNs and your social workers so they can work at the top of their license and not be bogged down with things that a clerical associate could take care of. Okay, observation. It is a key. It's a key compliance concept. We used to talk about observation for 23 hours. That kind of has gone away, but we're looking at 24 hours overnight. But it is a well-defined set of specific clinically appropriate services, usually in the signs and symptoms category. It's talked about in the CMS Internet Only Manual. You can see that on the bottom there. And that is sort of helpful, especially with your ED physicians that we're looking at signs and symptoms. We don't have a definitive diagnosis. We need to do some short-term treatment of them. We have to assess, we have to reassess. And then it's furnished while you're making a decision about what kind of care that patient is going to require as far as the status inpatient or outpatient observation. Okay, one of the things that is helpful is when you have an observation unit. So our question to you is, do you have a separate observation unit? And Lindsey, I'll let you introduce this. And then Tony, I'm dying to know if anybody had a comment on your long length of stay patient. That polling question is up on the screen here. I do see several of you responding and I have some questions here as well if you don't mind. While you all are answering this polling question, we'll take just a moment and pause and address your questions. So this first one that I see here is, can you give an example of when you should keep a patient in observation a second night after they have already been in observation for one midnight? Okay, that is very, that's a really, really good question and probably the best, I'm going to give you the most common reason is because that's what the physician says they're going to do, but let me give you an example. This is a patient who has signs and symptoms and they can't seem to get the, to the bottom of what's going on and there may be blood, some blood pressure fluctuations, there may be some heart rate fluctuations, there may be some lab work that is, I know I use the word funky, but that's what I, it just doesn't align up with what's going on with the patient and they feel like they need a little bit longer to observe them. Tony, do you have anything to add to that? Yeah, and to use CMS's words, those instances should be rare. It sometimes happens that you don't have a place to send the patient. If the patient is no longer clinically, clinically appropriate for observation, you know, sometimes folks just keep them that extra day, sometimes two days, we've certainly seen that, but that's where your inpatient, outpatient and an inpatient bed may come into play. So let's say at the end of 24 hours, the patient really could be discharged and you're having a major issue with that. That patient doesn't clinically, you always want to think clinically, right? So Bev described the clinical situation in which you might extend the period of observation and maybe it's just a few more hours to Bev's example, but when that patient really isn't meeting observation criteria and you don't have what to do with them, then that's where that outpatient and an inpatient bed might serve you. So you take the patient out of a clinical level of care and you put them in a holding pattern basically. And again, that should not be common and like Bev said too, sometimes the physicians just, that's what they want and that's not, you know, a good answer, if you will. So anyway, that's my answer, if that helps. Perfect. And then a couple more questions here. This first one says, I'm interested to hear how medical necessity impacts converting to inpatient from observation service. Are there different criteria for observation services versus inpatient or own medical necessity? Yes, there are. And you'll find that in any of the medical, for example, Change Healthcare Interpol or Milliman, they'll talk about that. Exolis, which is Cortex, I remembered the other name, excuse me. Cortex has points, but the others do define observation care versus inpatient. Okay. And so if a patient has been referred for a second level review and is no longer meeting observation or inpatient, is it appropriate to move the patient to outpatient in a bed if that patient has, I guess it's a social determinants of health keeping the patient there? And that's just, yeah, that's exactly what Tony had talked about. And the other thing is, you would stop counting observation hours then, whoever's doing the tracking of observation hours. Yeah. Thanks, Bev. I should have said that. Thanks. That's okay. Okay. And then do any critical access hospitals have the ability to have an observation unit with a 25 bed max? That is a good question. And I do not know the answer to that. I doubt it very seriously, because I think if I remember correctly, your swing beds count in that as well. So I'm not sure. Okay. Go ahead. Oh, no, I was just going to say they could check their managed care contracts, I guess. See if there's any language around that. And maybe we can try to find something about, Bev, do you think we can find that answer? Oh, let me check. Yeah. Yeah. Okay. Okay. It's a good question. Yeah. Sorry. Absolutely. No, you're good. So this says, so if all the physician documentation that you're recommending is in and the advantage plan still denies inpatient, do you recommend the peer to peer for each case? We tried this with a rib fracture, weakness admission, and acute pancreatitis this week, and both were still denied, even though they were three day long admissions. Next week, I'm going to talk about things that managed care plans hate to have reported to your state or to CMS. So we will be, I mean, sometimes you just have to do what you have to do. Acute pancreatitis, give me a break. So what about rib fracture and weakness? I mean, come on, you know? I mean, I would ask the question to the individual who said that. I would say, why was the patient admitted in the first place? But okay. Okay. There's one more, Bev. Yeah. And this goes back to your example, I think, Dr. Sessa, that says, so in your previous example, would you change the patient from observation to outpatient in a bed? Yeah. If there was no clinical reason whatsoever to keep that patient in observation, that's what I would do. Because otherwise, you're continuing, you know, keeping that patient in a level of care that you know they don't meet. And that doesn't serve anybody. Yeah. So I do remember you can't bill for inpatient, outpatient, I'm screwing that up today, outpatient and inpatient bed. But Medicare wants that because they want to track those bed days. Medicare watches your acute bed days. And so if you've got non-acute patients in inpatient beds, you know, inappropriately or observation beds inappropriately, they will pick up on that because it skews. I worked a lot with that when I was a senior VP. And so that's the broader reason why you don't want to do that, because it does skew your numbers at a high level. But having said that, you really do bottom line want the patient to be in the level of care that they're supposed to be in. And if OBS is over, OBS is over. And then just a clarification here, Kenton, this person was asking if you can state that again regarding the payment for outpatient and a bed by CMS impacts of tracking that number. Yeah. What I'm saying is if you have inappropriate patients, patients not meeting acute level of care or observation level of care in those beds, it skews your Medicare numbers. It makes it look like you have more appropriate admissions than you actually have. And a lot of what Medicare looks at is your bed usage over a period of time, you know, and those numbers are used to determine your rates and, you know, all sorts of things, your base rate with your DRGs and things like that. So that's a higher level reason. But at your level, you know, you just, all you have to, your job is to figure out what level of care that patient meets and have that patient in that right level of care. And we just see so many patients just kept in observation because nobody knows what to do with them. And that's really not appropriate if they no longer need it. And when they do need a little more attention by the physician, another 12 hours or whatever, okay. But again, you know, you want the physician to think it through. And the other thing is we want case managers to get those tests and treatments expedited while the patient is in observation so that we don't extend the time. And so, you know, one of our roles, you want to have a case manager who's really focused on those patients. Now, in larger hospitals, we certainly recommend a dedicated unit for that reason. But in a smaller hospital, you may not have the luxury of doing that. But as Bev said, you want to make those a priority every morning because you want to make sure that stress test gets done or that MRI gets done or that treatment gets done quickly. So, a focus on those patients specifically is important. And I know I'm taking up a lot of time. So, I will be quiet now. You're good. I'll go ahead and end this poll and share those results here so y'all can see that. Okay. Oh my goodness. So, we do know that when you get observation patients that are scattered throughout the hospital, it's so much more difficult to put them as a focus. So, we're not going to spend a lot of time on observation. But I will tell you the one thing that's going to happen is Tony is not going to shut up because she is our expert on outpatient surgery and observation service. So, here we go. I don't know about that. Well, first, before I do the next couple of slides, Bev, I want to give a shout out to Joanna. I don't know if Joanna is with us today. She was with us last week. I did write Joanna down last time. Oh, she just raised her hand. So, she's here. Oh, great. Hi, Joanna. Joanna contacted me right before we started this series. And she and I got into a dialogue about observation following ambulatory surgery. So, thank you, Joanna, for bringing that back to my attention because it turns out that it's one of the questions or concerns that so many case managers have. So, you're welcome and thank you. So, observation after ambulatory surgery is one of the things that has become, it's evolved into incorrect use. I think I gave the example last week perhaps. I had ankle surgery and the doctor orders me for the surgery and then immediately following observation. That is not correct. Now, think of that when patients go into observation in the ED, it's because the physician really doesn't know which way they're going to go. Are they ultimately going to get admitted or discharged? And so, how does the doctor know that before the patient even goes into surgery that they're going to need observation? So, think that way first of all. And so, secondly, the physician should not write an order for observation before that surgery. You cannot use observation immediately after surgery either, and I'll explain what that means. Post-operative complications can sometimes fit into the time frame, but I'm going to talk about that too. And so, only during the post-operative period and after the allotted extended recovery period have been completed. And for a traditional Medicare patient, Medicare says you can keep the patient in a recovery status up to 24 hours. So, you have a lot of time before you're going to start thinking about observation. So, it's become kind of a bad habit. So, let's say the patient has late in the afternoon, they go into surgery at 4 p.m. or something. So, they're getting out of surgery, you know, I don't know, 8 p.m. or something. They're going to stay in an ambulatory surgery status while they're recovering. And the typical recovery periods are 4 hours or 6 hours. Those are the typical amounts of time that are allotted to this recovery period. But again, you can extend that. So, the patient remains in a recovery period that's usually specific to the surgical procedure that they had, but it can be extended. And that really should be complemented with physician documentation as to why that period of time is going to be extended. And I totally get this. Let's say the patient is ready to leave at 11 p.m. and we don't feel comfortable asking a family member to come and get a patient at 11 o'clock at night. Now, the patient is recovered. They don't need observation either. They're, again, outpatient in an inpatient bed for the, as a service to the patient and family, it's the right thing to do. But you don't want to put them in observation. Okay. So, when you would consider observation, then, is anything requiring additional time beyond the 4 to 6 hours. But again, you could theoretically go up to 24 hours. But if you're getting a real sense that there's some, you know, issue with this patient, then, yes, you know, you can consider observation at that point. Again, like we said, these are not cut and dry things. But CMS actually gives us this list right here that may qualify as an adverse reaction. And again, all clinical where, depending on how severely ill the patient is, they may be appropriate for observation. So, this could happen, you know, during the period of time So, nausea and vomiting, you know, fluid imbalance, pain, arrhythmias, and so forth. So, these are clinical reasons for observation. Always, you need to have that clinical reason where there's been an adverse response after surgery. So, that would, you know, qualify. Again, some of the things that we've talked about, you know, is that, you know, So, that would, you know, qualify. Again, some of this is a little subjective, but these are pretty clear adverse reactions to consider, and the physician should really document that as well. So, the order should only occur at that point in time if the physician is, indeed, going to order observation. I know there's some questions, but we're going to wait on that. Yes. Yeah. Well, it's up to you. Yeah. Yeah. We'll wait to the next poll, I think. So, hold your thoughts. You know, I do have those into the Q&A in the chat. So, yeah, continue typing those in, and we'll certainly address all of those at the next polling question. Okay. I do want to add, Joanna also did, you know, the resource that we put in your resources at the end of this slide deck, and one, Tony, that you use a lot, that really talks about that. It was even updated years ago, though. I mean, I think several years ago, and Joanna, I think that was what you had put in the chat last week, that that was a recommendation. So, that was really good. Yeah. Yeah. Yeah. Thank you. Yeah. The clock, the calendar, and the two midnight rules. So, the two midnight clock, the benchmark clocks, begins when the beneficiary begins receiving hospital services. Now, what CMS says that it can include the start of care after registration and initial triaging, observation care, emergency department, operating room, or other treatment services. So, as soon as that patient really begins to be looked at, and, you know, some of your EDs, you're going to have longer waits, and you may triage a patient, and you'll watch them for, they'll watch them for a period of time until there's a room available in the back, as we say, and a physician available to see that patient. So, that's when it's going to start. It's all about the timing. So, let's take a look at this calendar. And so, you have a patient. I'm using the example at the bottom. You'll have a patient that comes into the ED at 10 p.m. on the 8th, and they're placed in observation service. Then they are, okay, so on the night, they're admitted as an inpatient. They're discharged on the 11th. How long does the inpatient stay? Okay. Well, and you can answer this in your head. This isn't anything that you need to put in here, but what, the way CMS looks at an inpatient stay is, for the two midnight rule, that night in observation, if they go to inpatient, really counts as inpatient. So, this patient actually had three nights as his inpatient stay. Hang in there with me. So, the 8th, the 9th, and the 10th, they're there. The 11th, they're discharged. However, on the converse, the rule for skilled nursing facilities is they have to be inpatient for three midnights. So, while CMS will call this a three-night stay or a three-day stay, this patient could not go to skilled nursing facility unless they wanted to pay for it, I guess. But that is confusing. It's not all real easy. So, this is just what I said. And the other thing is that while the Medicare Advantage plan is following the two midnight rule. They do not follow the three midnight inpatient stay requirement and so they can send a patient to a skilled nursing facility earlier. So I hope that's clear as mud, but let's just do a little bit of math here. One ED observation midnight plus one inpatient midnight is inpatient. CMS counts that as a two day inpatient stay. Two inpatient midnights are inpatient. One obs midnight plus two inpatient midnights, no skilled nursing facility. And one ED midnight plus one obs midnight plus one inpatient midnight does not equate to a skilled nursing facility. So it gets a little tricky when we're working with the requirement for discharging a patient to a skilled nursing facility. Okay, let's talk about more rules and regulations here. So we gave you two attachments. We'll talk about the third one in a minute, but if you are in an acute care hospital, then you are going to have your own conditions of participation. The other thing I do want to mention to you, and psych has their own special conditions of participation, but up at the top left, any state regulation that's more restrictive than the condition of participation is going to trump that condition of participation. So I'm gonna give you an example of that. I can't really think of any medical necessity examples, but when I had HIM, I had medical records answering to me and CMS, because there's conditions of participation for every department in your hospital. We have conditions of discharge of participation for discharge planning, as well as utilization review. But in Texas, the Texas law was that your history, I don't know, maybe your discharge summary had to be within a certain time, or your history and physical had to be written within a certain time, but it was different than the conditions of participation, and it was more restrictive. It was a shorter period of time. So when you are surveyed by any hospital surveyor, accreditation surveyor, they are going to, and you've given them what we call deemed status, then they're also going to survey you for the conditions of participation. If you're a smaller hospital and you're being surveyed by the state health department, they're going to really focus a lot on the conditions of participation, as well as any rules that they might have that are specific. So attachment one is the inpatient prospective payment system. That means that you get paid by the DRG and it's utilization review. That is attachment one. Critical access hospitals, you are not paid by the DRG by Medicare. Usually you do have options, but most are not paid by the DRG, although you are paid by the DRG by your managed care plans or your commercial plans, if that's what you've agreed to. And so it is silent on the mention of utilization review. Okay, so the two midnight rule though, applies to the critical access hospitals. So we begin to think that what some of the rules and regulations that occur in the conditions of participation probably are applicable to you when the critical access hospital. And then you psychiatry hospitals, do you win the prize for the longest conditions of participation? So yours are quite detailed, but the things I'm gonna talk about here are things that are in both of your conditions of participation. It needs to be a committee of the medical staff. You need to have two or more physicians, MDs or DOs. And there must be some sort of review that's conducted of professional services. So duration of stays. And this committee really needs only to review things that are based on extended length of stay. So what we often see in a UR plan, which we'll talk about in the next slide is that the extended length of stay days will be identified. Be careful. If you say we're gonna report to the committee every length of stay that's over five days, okay, that could be a bit tough. Maybe you determine, maybe your extended length of stay is 10 days. It's whatever you say it is. And that's what the accreditation agency is going to, I'm gonna say judge you on. They're not judges, but sometimes it feels like it. I've certainly have spent, Tony and I have spent our days going through that. Medical necessity reviews performed by this committee can't be conducted by an individual who has direct financial interest. For example, an ownership in the hospital, and there is a percentage there, and I can't even remember what it is. I wanna say 15%, but I don't remember. Or was professionally involved in the care of that patient whose case is being reviewed. So that doctor would need to recuse himself if a patient was discussed. And here we are. Do you have a UR committee? Okay, let's get that one pulled up here. Ooh, I'm looking forward to this one. I see you're all answering that question quickly. And we do have a few questions that have come in for both of you real quick. We can go through these. So this first question asks, we often have their pre-starters for the MD office that will get the prior authorization for surgery or hospital admission as observation prior to the surgery. How would you handle that? Wait a minute, observation prior to the surgery. It says we often have the pre-starters who work for the MD's office that will get the prior authorization for the surgery or hospital admission as observation prior to the surgery. I'll tell you what, if it's a commercial plan or a Medicare Advantage plan, those pairs can do whatever the heck they wanna do. Yeah, yeah. I was struggling with where would the patient go? I mean, I guess they would go to an observation bed. Yeah, well, anyway, go ahead, Beth. No, most of these people don't have, they'll be scoundred. Oh, that's right. That's right. We're not laughing at you, we're just chuckling with you. No, no, no, we're kind of laughing at ourselves, actually. Yeah, but I think that when it comes to, when it comes to the rules and regs for a commercial payer, they're making their own rules and regs. What I would say is it'd be interesting to see if your contract addresses that, but. Well, and even on the Medicare side, I think my question to the person who asked this question would be like, what was the clinic, do you get a clinical rationale for why a patient would need to be observed? And if so, why aren't they just going to surgery immediately? Usually that's the physician's preference and his or her schedule. There was a comment, I don't know if it's from the same person. Oh, no, I don't know. Okay. I guess it might be in this other one. Okay, so ask the, you know, ask if it's clinic, you know, we're stumbling because I never heard of it before, but, you know, there may be some legitimacy if a patient, but if the physician is still observing the patient and doesn't know what he or she wants to do with them, but they're ordering surgery, that's a little scary to me. So I would ask for more information. My question is, are they ordering observation now and then surgery, or are they ordering observation ahead of time for after the surgery? That's how I took it, so. Oh, I took it the other way around, but you're probably right. And then we've kind of talked about why that's not a good idea. Okay. I think that person may have added something, so, okay. Okay. This next question asks, do certain procedures automatically qualify for a certain number of observation hours after the surgery, or does that always need to be authorized separately? And then also if a patient has a secondary insurance, does that need to be authorized separately as well, or does only the primary insurance need to be authored? Okay, on the first half of the question, no. It should be based on the patient's clinical status during the recovery period, and you don't know whether the patient's going to suddenly start bleeding or suddenly become excessively nauseous or have chest pain or whatever. You don't know that prospectively. So, only when and if the patient begins to show some clinical issue that warrants observation status. The second half about the billing or authorization, Bev, I'm turning that back to you. You know what, I think that's going to have to go to probably your finance department because I think that's going to vary and may vary by payer and it may vary by state. So, I don't feel like I'm able to answer that. Yeah, me either. Okay, and so certainly reach out to your team there at your hospital, and again, as I mentioned, state regs may vary. So, if we can help and you're a member of GHA, don't hesitate to reach out and we can possibly help you track down an answer to that. Okay, this next question says, we at times use extended recovery versus outpatient observation. However, I have been told the observation and extended recovery CPT codes are the same. Not sure how Medicare would know the difference. Extended recovery, we change them to this when normal post-op issues. And then I guess for the group here, do many people use extended recovery? So, maybe y'all can answer that there in the chat. If the patient is registered, meaning you're changing their registration status from ambulatory surgery to observation, I find that very hard to believe that those would be the same codes. If they are, they are. However, you've got to do what is appropriate clinically. You have to make sure you have the documentation and all of that, and just because if it's true, the codes are the same, that doesn't negate your requirement, the expectation that you'd be compliant and keep the patient in the right level of care. So, you want to make sure it's changed and re-registered with another registration code as you would in the ED. Okay, and then I think there's just two questions. I hear this. Yeah, there are lots of questions. The observation or inpatient length of stay calculation is critical for us and 340B eligibility. Is the regulatory guidance available in that handout? And I think she did just look through and didn't see that there. Or could you please note the CFR? If you have that. Could you repeat that again? Yeah, go ahead. If you could send that question to us, we will answer that. Absolutely. Yeah, yeah. I think, I was just going to say that reference that we have at the end of the references refers, I think, to Medicare, but we'll double check on that, yeah. Yeah, and I mean, 340B is decreasing all the time. So, we don't want to mess that up for you. So, yeah, if somebody, Lindsey, if you can send that to me, we'll look at it. Okay. Yeah, happy to do that. Okay. Do they have a UR committee? Or is there another question? Nope, this is, I have one more, I think, here that just says, we have a physician that leaves patients for two midnights as part of his protocol. Would these patients be, and I'm guessing here, outpatient in bed is OIB, the acronym for that? Not really, I've never heard of one, but yeah. That's what that is. Yeah, for the- You know, that's where your physician advisor comes into play. And see if that physician, if they're in an inpatient, if I understood right, they're in inpatient for two midnights, that's where your physician advisor has to come into play. Okay. I'll go ahead and end this poll and share that result there. Oh, nice. Nice. Congratulations. Yes. That's great. Very good. Excellent. Oh, here are the claps going. Thank you for the clapping. Okay, I am gonna rush through some of this. And if we need to address more, we can, but I wanna give Tony plenty of time. So everybody has to have a UR plan, and that plan talks about how services are gonna be reviewed, how they're gonna be furnished, and what's gonna happen in the hospital, and what's gonna happen in the medical staff. Hospitals have to ensure that all UR activities, including medical necessity review of hospital admissions and continuous stays are fulfilled. And then as I mentioned, psych hospitals have a much more in-depth UR plan requirement. Now, we were talking, I think Tony, you were talking about this. Oh, excuse me. My gosh, I accidentally hit my, okay. There you go. Billing can occur anywhere. And Tony, I think you mentioned this last week as well. It doesn't matter what bed the patient's in. So like we talked about, if you're holding a patient in the ED and they're waiting for a room in the hospital, moving to inpatient, you get credit for the inpatient nights, especially if they're Medicare. But just a reminder that billing can occur anywhere, including the ED. Okay, let's talk about the process. So, this is what you do as a case manager. A patient is admitted. You do chart review. You do a bedside review of the patient. You use your medical necessity criteria and your patient meets criteria and you determine a date for the next level review. One of the things that Tony reminded me is that in this, you're gonna talk to the physician. If your record is cut and dried, you may not need to talk to the physician, but it's so great because you also wanna know what the discharge plan is, when a patient's gonna be moving out, or if they're in ICU, when are they gonna go to the next level of care? How do you know when it's time to do your next review? Well, there's several things. The department medical necessity review policy may be there. You may say every three days. I get nervous about three days or five days. Tony, I know and believes and I'm with her that in the ideal world, you should be able to take a look at those patients every single day. That may not be possible based upon your workload, but your department might require it. Your patient complexity may make a difference. A payer request saying, okay, there are some payers that want daily reviews. Some payers that say I need a review in three days, whatever. And then your physician advisor recommendation. He may say, okay, observation is okay for tonight, but let's review tomorrow and see what's going on. Okay, but if the patient doesn't meet criteria, let's go through this process. You talk with the physician. There's no additional documentation. Okay, hang on here. We're gonna go to the next slide and we're gonna talk. We're gonna come back to this one. As a nurse of the first level review, we've talked about this before last week and earlier even today. It's an audit and not a judgment. So when your discussion with the physician occurs, it is not, hey doctor, your patient doesn't meet medical necessity. You can really irritate physicians easily by doing that. And I think we've all had to learn over time how you deal with each individual physician, but I'm doing a first level review. Your documentation doesn't support my guideline. Is there anything else that you have to add? And then you might've seen something else in the chart that leads you to a discussion with them. But if there's no additional documentation, then just explain to the physician. I'm gonna refer it to our physician advisor and let him take a look at it because he may be able to understand medical necessity. So now we're gonna go back to that same slide, right? Where the arrow is underneath the necessity criteria words. So you refer it to your physician advisor for second level review. If the physician advisor agrees with you that medical necessity is not met, then they're gonna speak to the physician. If the physician agrees with the physician advisor and discharges the patient, great. Or as we would say in Oklahoma, hunky dory. If the physician disagrees with the physician advisor, then a second utilization management committee member is going to review. And that process is described in your condition of participation. And then a determination is made. And actually what happens is that physician's able to make a response and maybe even an argument for why they believe that patient should be inpatient. For example, when they only really meet observation service and your physician advisor agrees, but they have that option. If they don't then work through with you on that, then you can follow the process of the UM committee to set a discharge to the next level of care. But let's go to the bottom where the lighter things are. If the physician advisor believes that medical necessity is met, and you don't have that in your first level review, if you've got questions, escalate it to your leader. There's no problem with that at all. And continue monitoring medical necessity, taking into account the PA discussion, and then you continue that discussion with the physician and or the physician advisor. Don't just drop everything. So the perfect world then, incorporating to midnight compliance into your daily routine is, you get the patient, you get the appropriate order, you review it, your first level review is appropriate, the physician does good documentation, they have a one or two day stay, the patient's discharged, and they bill appropriately. And then the nightmare can occur. And that's just Murphy's Law. So we gave you attachment three, which is the midline matters, number 844. Huh? No, I'm sorry, nothing. Oh, anyway, which is 8445. And so now your patient is admitted. And this is where we begin to get into a condition code 44. Or we are doing a self denial of the patient. So patient comes as an inpatient, the documentation is not there that supports the compliance of the two midnight rule, one or two day stay occurs without a case manager review. So we're talking maybe Friday night, and this is Monday morning, Saturday night, and this is Monday morning, and the patient is discharged, you need to put that account on hold so that you know that you have billed that patient appropriately. The case manager, then someone will do a retro review after discharge. And then if there is not a support of medical necessity, it goes to the physician advisor for agreement, and then you will have to self deny. This is for the traditional Medicare patient. So that is what would need to be followed. If the patient hasn't been discharged, then here's where the condition code 44 is, rather than on the last slide. I'm sorry, I popped that in there. Patients admitted as an inpatient, the physician documentation is appropriate, you escalate it to the physician advisor, and they agree. And then the attending physician and a member of the UN committee agree that the patient should not be inpatient status. And you know what, I actually should say there, let's say the attending physician, yeah, and you're a member of the UR committee, so that would be your physician advisor. If your physician advisor ought to be a physician member of the UN committee, they discuss that, and that physician says, you know what, I just missed it. Sorry about that. I don't understand this stupid rule anyway, whatever they want to say. But that physician then says, I agree with the UR committee physician member, and that has to be in the medical record for you to appropriately build what's called the condition code 44. But the patient has not been discharged, and the patient is given the moon, and Tony's going to talk about the moon in just a little bit. If the patient is discharged, then you still have the physician advisor look at it. You don't give a moon, and then you do the provider liable billing or condition code 4121 or W2. There are a variety of different codes that are there. So as I mentioned, everything has to be met here, that there's a change from inpatient to outpatient. The physician has to concur with the physician advisor. The hospital hasn't submitted the claim. I don't know why anyone thinks we'd submit a claim before the patient was discharged anyway, and then that physician agrees. What we find is that many hospitals have an order that's in their EMR that says, I agree with the UN committee recommendation that this patient is not an inpatient. So it's all about the billing process, and the bottom line is, did the patient go home? If they went home already, they're a provider liable. If they're still in the hospital, it's condition code 44. This part is traditional Medicare only. Okay, man, I tried to rush as quick as I could, Tony. You did good. You did good. And look at this. We saw at the beginning that very busy slide with all the different kinds of rules and regulations, and I guess, Bev, you know, we could probably talk all day about all of these things, but we're going to touch on them now just so that you have a sense of what they mean. And of course, the good old important message from Medicare, IMM. So typically, your first important message, as you know, is given in your patient's admitting packet. This is one form that the patient must sign. So that's typically done in the admitting office. The second message, as per Medicare, is required to be given within two days of discharge. And what they don't want to see that it is routinely given on the day of discharge. If you read the regs really deeply, it actually says the patient should sign the same form that they signed on admission, but we don't usually do that. We usually give them a second form to sign. But the whole premise is that you want the patient to have time to appeal. This is their right to appeal notice. And so if you're giving it as they're going out the door with their discharge information, then you're really not following the essence of this particular regulation. There were some updates on the IMM that came out in April of 22. So they added this formal exception that the patient discharged to inpatient or outpatient hospice does not get an important message. Patient changed from inpatient to outpatient using condition code 44 does not have expedited appeal rights because you're basically downgrading them to observation. Prohibits giving an IMM to a patient not formally admitted as an inpatient or with inpatient admission is pending. Or it should say or when inpatient. Yeah, thank you. That is. Yeah. Yeah. Yeah. Sorry about that. So they really don't want you to give it to everybody just in case you don't miss anybody. The second IMM must be given no later than four hours prior to discharge. But again, you don't want that to be routine at all. You want to think ahead. You can give it the day before discharge when you're preparing all your other discharge materials. It may be presented and signed electronically, but the patient, again, has to be given a copy. Now, this last one's a little funky. And when it came out in 22, I was like, whoa. So if delivered to a family or a patient representative who is not physically present, so the patient's daughter is in another state, you have to speak to them verbally, probably by phone, and send them a copy of the IMM with a way to get signature verification of delivery. So. I think that was a coded thing. Yeah. But it happens. It doesn't happen all the time. True. Right. You know, usually the patient can sign it, but if not, this is what you've got to go through. I would, you know, personally, I would send an email if it's HIPAA compliant and then have the person say received or something like that. That would take care of that. Okay. So we know about ABNs and HINs. So the ABN is the Advanced Beneficiary Notice. This is an outpatient form. It's optional, of course. It is applied when the outpatient services are or may not or may be denied. So it's an anticipation of or actual denial of outpatient services. You can also give it after observation service criteria is not met. So the HIN is, you know, the one we often think the most about. Hospital-issued notice of non-coverage. Again, it's optional. Medicare does not require that we give HINs, and we have to remember that. Notice that inpatient services are or may be denied is the purpose of the HIN. So there are things to think about about the HIN in particular. I have to say, and I know I've said it before, when I was a director, I was very thoughtful about when I said, okay, give that HIN, because it does create kind of a less than pleasant relationship between us and the patient. But there are occasions when it's absolutely necessary. So you may issue a HIN to a Medicare, traditional Medicare patient, if you plan to hold the patient financially liable. So first of all, that's the other question. Are we really going to bill this patient after the fact? So we have the specific, no, no, go back. I'm sorry. I rushed you. I'm sorry, Tom. We have the specific reasons when the care that the patient is receiving or is about to receive is not medically necessary, not delivered in the most appropriate setting, or custodial in nature. So those are the criteria for when you would consider using a HIN. You also want to contact the physician to see if there's any additional information that he or she can provide that would take you out of one of those criteria, like not medically necessary. You want to include your physician advisor in the process. The patient must be able to comprehend the HIN. So if they can't comprehend the HIN, there's no reason to give it to them. And where you're using EMTALA, and that's obviously in the emergency department, you would not give a HIN there. The patient billing must meet CMS requirements. So if there's an error made in billing, then you're not going to get any money. And same thing with the HIN. If you don't give the correct HIN, the patient cannot be held liable. So let's look at now at the four kinds of HINs that we would think of using. HIN one is the pre-admission or admission HIN. And this is what you're going to use when prospectively you can see that an inpatient order does not meet the level of care or the medical necessity for inpatient status. So this would be prior to an entirely non-covered stay. So that's important. And if you don't have anybody gatekeeping, again, you know, this kind of falls by the wayside. HIN 10, notice of hospital requested review. So this is when we, the hospital, go to our QIO, our quality improvement organization, and ask for a decision when the physician is not in accord with us or we can't. So in other words, what happens is we're in a tie and we ask the QIO to help us make a determination as to the status or the continuing care of that patient. HIN 11, use for non-covered items or services provided during an otherwise covered stay. So the patient is there for a legitimate reason and now the physician wants to do something unrelated or uncovered. So something like cosmetic surgery is a non-covered item and you don't want to be doing that while you're doing some other surgery or something. HIN 12, the most common one used, patient initially meets the inpatient level of care but no longer needs inpatient care. The physician is in agreement with you, unlike HIN 10, that the patient should be discharged, but the patient does not want to go. So you use that in association with your detailed notice of discharge and that informs them of their potential financial liability should they continue to stay in the hospital. So, you know, looking at those dollars sometimes is helpful. Okay, so regarding the notification of discharge appeal rights, it provides the specific explanation of the reason for the discharge. The HIN 12 notifies the stay is no longer medically necessary and the patient doesn't want to be discharged. The detailed notice of discharge, the DND, is given to the patient who appeals after receiving the HIN 12. All required information then you need to send. So the patient's appealing, now all of the information in the medical record that's required is sent to your quality improvement organization along with the IMM and the detailed notice. So they have to get that packet of stuff that they're going to look at. They have 72 hours to make their decision after all information is received. Is that right? I thought it was 24 hours. Did they change that? No, I was looking at that because it goes back and forth. They have expanded it because the QIOs got so slow. And so that is the latest that I saw. Oh, wow. So rather than make the QIOs work harder, we extend the time. Okay. Yeah, we're busy. I bet you have some experienced patients that come in and want to start appealing the minute they get in the hospital bed. And sometimes you have to say, well, you're in observation service and so you don't have appeal rights. But we do know that that does happen. So wild and craziness. Yeah. Okay. Let's go on. The inpatient only list. This is a list for Medicare of usually surgical procedures that must be done as an inpatient. And it had application to your traditional Medicare patients. Also applies to your Medicare Advantage patients. So these are inpatient procedures. Patient is not required to stay in the hospital after the procedure, but they have to be inpatient. Any procedure not on the inpatient only list can be performed as an inpatient observation service or outpatient, depending on the physician's documentation. And the example I always use is the knee replacements that early on, they were one of the first that were taken off the inpatient only list. And so the impression from folks was that, oh, they can only be done outpatient. And that is not true. It's really up to the discretion of the physician. But, you know, you also want to be careful about when and how patients get admitted for something that's not on the list. Now, I had read that they were going to reduce the number of procedures on the inpatient only list, starting with orthopedic surgeries and continuing for after that to others, eventually eliminating the list entirely. So you can get the updated list online, but typically your surgical office takes care of that. But it's good to know if you have somebody who's gatekeeping, again, this is something for them to look at. Okay. Let's talk about the Notice Act and the MOON. I always kind of giggle when I say that. I'm sorry. Delivery of the Medicare outpatient observation notice, when it's given to the patient, which is the MOON, it explains to that Medicare patient, including your advantage patients, it's an explanation to them that they're in an outpatient status. And you give it after they've been in observation for at least 24 hours. All hospitals must give the MOON, including the critical access hospitals. So it explains the implications to the patient on the services furnished. In particular, any out-of-pocket they're going to have. I like they call it cost sharing. Very cute. Subsequent coverage eligibility for services in a skilled nursing facility. And we saw how that would calculate out if you were thinking of transitioning that patient to a SNF. It is signed, must be signed by the patient or their representative. Like any other form, if they refuse to sign, then the staff hospital member who presented the MOON would note that on the form. Okay. So you should know your U.M. rules and regulations by now, I would think, but let's go through the process. The Medicare patient is placed in observation after 24 hours at the appropriate time, the MOON would be delivered. So we hope you don't have to give out a lot of MOONs because that means you've got a lot of patients staying in observation past 24 hours. Now the patient gets admitted as an inpatient. The important message would be given. Documentation for why the physician expects the patient to stay at least two midnights would be in the record, hopefully, with an appropriate inpatient order and care would be rendered. Discharge planning begins. You want to get the patient and family involved in the discharge plan right at the get go and talk to them on day one. Again, the IMM would be given again. The second one within two days of discharge, assuming this day is at least two days long. Physician admission order authenticated before discharge. Discharge order is written, patient agrees, we're good to go, patient disagrees, then they're going to do the appeal process that we talked about, we're going to give the detailed notice of discharge, and possibly a HIN. So here, I just want to pause for a second, Bev, because here what you see is the co-mingling of utilization management and discharge planning. And so, when we separate them in some models, you have to have really good communication because there's so much back and forth in the discharge planning stuff, processes, that again, interfaces with the UM stuff. So I just wanted to make that comment. Okay. Now I'm going to take a sip of water. So this, here we're talking about the two midnight rule, self-audits. So any traditional Medicare patient with a short stay, and short stay is defined as one or two days, must have medically necessary, necessity, excuse me, review before your finance department sends out the bill. So here's an example. The patient is admitted Friday evening and discharged Sunday without a review being done. We would ask finance to hold that bill until we are able to complete the review. The case manager reviews the medical record as you would do. If the patient meets medical necessity, you inform finance to go ahead and send that bill. If the patient does not meet medical necessity, the physician advisor or a UM committee member would review the record. If they decide the patient meets medical necessity, then we bill. If the patient does not meet medical necessity, then we would use that self-denial process. All right. I'm getting very sensitive to the time here. So there are some payer issues that you want to be aware of. And the thing that gnaws at us so much when we work with hospitals is that case managers do not have access to the utilization management portion of your managed care contracts. And so when you don't know what the expectations are or the requirements are from that section of the contract, then it's really hard to be in compliance with those expectations. So we don't really call too much anymore, but we do send electronic reviews most of the time. And we just need to understand, is there a cutoff time for the review? What is the appeal process? There's lots of different things you need to know. So your finance people or your managed care department or whomever does your contracts really should provide the department with the UM section. There's nothing that is going to be given away. They don't want you to see the dollar parts of the contract. That's fine. We don't want you to see that, but we do want to see what we're supposed to be doing. We can't do it if we don't know what it is. So please get that contract. So your interdisciplinary team, aren't they cute? And that's me in the wheelchair there in the middle, I think. Never say that, there you are. With my ankle, yeah. But you know, you have a big team. It's not just you in silo. You want to know who your team members are, and if you are unit-based, which I hope most of you are, you're going to have a consistent team, hopefully, for the most part. You want to collaborate with all your team members, and you want to help them, you know, to understand those rules and regulations. And so, you know, every opportunity where there's an issue is a time to do some teaching. You know, you can sit with high-volume emitters if you can track them down and go through this stuff, but that's not really going to benefit anybody. It's probably better on an issue-by-issue, case-by-case basis to explain the rationale for something that you're discussing with them, like not putting your patient in observation before they go for surgery. Okay. So let's talk about best practice utilization management roles. There are a potpourri, should I say that, or a plethora of roles related to utilization management that you should have in your department, and we talked about ED. We'll talk more about that in our fourth webinar. Admissions and or transfer centers. Sometimes if you're small, you have to combine those. So we saw that maybe 50% of your admissions nationally, on the average, come in through the ED. That means 50% are coming in from all those other sources, and nobody's gatekeeping them. So the door is open, and everybody just kind of comes in, so you got to think about all those routes of entry. You should have an observation service case manager who's really expediting and throughputting those patients as well, and of course, your utilization management case manager, peri-op case manager, somebody helping with that whole period from pre-surgical testing through to the PACU, transfer center case manager, as I just said, and then denials and appeals, not necessarily a case manager, but a transfer center case manager. But a staff member. And then, of course, that support role we're going to talk about, I think, next time. No, it's good. Go. So leaders, you case management leaders that are with us today, you have lots to consider to help with your utilization management compliance, and I'm not going to read these because we are really short on time. So if you are a leader, I hope you'll come back and look at slide 60. It has all to do with how you design your department, how you're compliant in your department, how you effectively use your physician advisor, and your participation on the UR committee, how you educate, and how you collaborate. So please do think about that. You leaders are so important. It's one of the hardest jobs, I think, in the hospital, the case management director position. Okay. So now we have a few polling questions. Do you think we should do the questions in the chat first? Oh. I don't know. And then they could work on these together, but whatever you want to do. Yeah. We could put the first one up and then answer some questions. Oh, that's good. Good idea. Like we were? Okay. Yeah. So before we actually ask, excuse me, answer the polling question. Okay, never mind. Well, let me see. 75-year-old patient with traditional Medicare comes to the ED with abdominal pain on the 10th of the month. An order is written for observation. So we're observing the patient for abdominal pain, and while they're in the ED, I guess getting observation in the ED, his condition deteriorates, and he has emergency surgery. There's an error right there. I knew there was an error. The next morning, he is admitted as an inpatient. What's wrong with that? The order for surgery should have been written before the surgery, not the next morning. So that's true. Yeah. So that should be reversed. But in any case, now he's an inpatient. He's post-op. He recovers quite well and has an order for discharge to the SNF on the 12th. Can he be discharged to the SNF on the 12th? That's the question. Okay, I'll go ahead and launch that here. So you should all see that question here on your screen. And then we do have quite a few questions. So do you all want to address those now, or do you want to wait? Go ahead. Yeah, let's go. Let's go ahead. Yeah. Okay. How many are there? There's a lot. There's a good many, which is great. I'm glad that you all are participating and asking these questions. That tells you that it is a very needed topic to be addressed. I appreciate that. Okay. So this question says, most all payers have a policy. Most all payers have a policy in the provider manuals about pre-op care and the use of observations post-op. It's a no-no, and I don't think you can even bill observation hours with an outpatient surgery. So why put yourself on Medicare's radar? So that's a comment there. Okay. This says, I am curious how many facilities have a physician advisor for a small critical access hospital? I'm not sure how this is feasible. Do you have recommendations for how we could get leadership to agree to this position? You know what? We will put that in when we talk about physician collaboration, because we do have some ideas. We do work with some critical access hospitals. So we will add that into physician collaboration and webinar four. Okay. But the quick answer really is, you might want to look at one of these companies that does physician advisor work remotely. Anyway, go ahead. Okay. What is the requirement to change the status order? We use Epic and are expected to change the status order from inpatient to observation. It has always been my understanding that we never touch status or registration. That's usually a no-no in a hospital, that that has to be done by the registration staff. So that's always been my experience, and I've worked in a lot of hospitals. You really shouldn't be touching that. That is not within your area of responsibility. I don't know if you have any other thoughts on that one, Bev, but I would not do that. No, that's fine. Yeah. Okay. And then this next question says, so if the patient does not want to appeal the discharge, can it be documented that the patient denies the appeal and does not need the four-hour window after the IMM follow-up copy is given? The four-hour window? The four-hour window? Oh, so in other words, you gave it four hours before discharge and they're not appealing? Oh, so that they have to, because that four hours gives them time to consider whether they want to appeal or not. I mean, I guess you could. Yeah, I guess. Yeah. I mean, I wouldn't make it that close myself, but. Or even that clear to the patient, just you have the opportunity to appeal and they say no, then okay. Okay. Is a hint appropriate for comfort cares? There's no such thing as comfort care. I hear that a lot. Comfort care. There's no such thing as comfort care. Okay. There was no, a lot of hospitals use it. It's become sort of, you know, in the hospital, that's how we do it kind of thing. But there's no such thing as comfort care. So can I hear the question again? Is a hint appropriate for comfort cares? Is a hint appropriate? I don't think so. I would not give a hint to someone who's probably should be in hospice, not in comfort care. That would be my answer to that. So comfort care is not a real thing. Yeah, I would add. I mean, I think comfort care is a palliative care term because I experienced it when my uncle was in the hospital, but I would say anytime you're giving a hand where you're going to build the patient, then that needs to be an executive level decision that's agreed upon by the leaders of your hospital. I don't, I think there's no problem with doing it, but I think everybody needs to understand and agree that this is how we're going to approach this individual patient or this group of patients. Well, I, you know, my point, my point was, do you really want to give a hand to somebody who's actively, you know, dying? Right, that's, that's why I think, yeah, yeah, yeah, yeah. Okay. Okay, and then do you give the hand 12, I mean, 12 hours prior to give the hand 12 hours prior to the QIO contact or after the QIO comes back with a decision that appeal was not upheld? Typically, we give the DC, IMM and DND. After. After the QIO's response, yeah. Yeah, that's fine. Okay, let's see. Like a comment here. Okay, so this says the issue is if a patient is here over the weekend and the IMM is not able to be given by case management because we are not here over the weekend and then the patient discharges on Monday morning. That is how the four hour window often happens. The patient admits on Thursday, and even if I was to give an IMM on Friday afternoon, it would not cover them on Monday morning discharge. Right, right. I mean, some hospitals ask for nursing to do that. I would say you need to have staffing over the weekend, but in the absence of that, maybe nursing needs to learn how to do that. You know, you have an unexpected discharge or the time frame is off, like you're saying. Either you need more staff or some other department has to step up. Okay, all right. I think that's the last question. I'll go ahead in this poll and share those results there. You all have some really, really, really good questions and really good answers. Yeah, look at that, Bev. Excellent. Nice. They used your math earlier. Okay, let's go. Next question. Oh, I'm sorry. That's me. Hang on a second. No, it's not. It's me. Which of the following does not fall under the umbrella of case management regulatory compliance? This one should be easy. Don't you think? I would hope. Looks like we're getting lots of the same answer here, so I believe so. But just another second here. All right. Okay, I'll go ahead and end that and share that. We've gotten 100% of the same response here. I love it. Thank you. Everybody knows that. CMS expects that one-day inpatient stays should be all chest pain patients, more common in the future, dependent on the judgment of the physician, reimbursed at the full DRG level, rare, B and E, C and E. CMS expects that one-day inpatient stays should be all chest pain patients, reimbursed at the full DRG level, rare, B and E, C and E. Good responses coming in here. Give it just another couple of seconds. Okay. Okay, perfect. We'll go ahead and end that here and share that result. All right. I'll say that. It might not let me share. It's frozen for some reason. It looks like we had 50% C and E, 48% rare, and then 2% dependent on the judgment of the physician. Oh, here it goes. Now it's letting me share. Okay. Okay, so the correct answer is C and E, C, depending on the judgment of the physician, that's CMS language, and should be rare. So those two are correct. So they actually got it, but yeah. Yeah, yeah, yeah, exactly. You got it, but you didn't get the two together. Just a couple of people. So yes, it's, okay. CMS expects that one, yeah. Oh, I'm sorry. I'm confused. Okay. No, I was just saying CMS expects one-day stays to be rare based on the judgment of the physician. So that's that. Okay. Let's move on. In the conditions of participation for utilization review, all hospitals are required to have which of the following? Okay, I see your responses coming in here. You know, we've talked about all of these rules and regulations, and then you have a three-day weekend coming up that's just going to throw everything in the mix for you all. This is true. We do remember those days, don't we, Tony? Oh, for sure. Okay, we've gotten some good responses here. There you go. Okay. So, the COP for utilization review specifically, the correct answer, I think, Bev, is utilization review committee. Yes, that's true, because discharge plans are covered under the COP, and they're not covered under the utilization review committee. So, that's true. Okay. We didn't mean for that to be tricky.

utilization management

hospitals

regulations

two midnight rule

CMS

observation service

inpatient status

patient status determination

compliance

notifications

medical necessity reviews

leadership

payer policies

collaboration

efficient care delivery