to kick off the final part in our series. Ms. Bev Cunningham has been a partner and consultant with Case Management Concepts, LLC, since its inception. Previously, Bev served as the Vice President Resource Management at Medical City Dallas Hospital, where she was responsible for case management, health information management, patient access, solid organ transplant, and transplant financial services. Bev has been involved in the development of case management for over 25 years, and her areas of expertise include the role of the case manager in the revenue cycle, compliance for case management departments, the role of the physician advisor, and effective denials and appeal management. Bev has achieved ACM certification by the American Case Management Association. And Dr. Tony Sesta is a founding partner of Case Management Concepts, LLC, a consulting company that assists institutions in designing, implementing, and evaluating case management departments and models, educational programs, and on-site support for leadership and staff. Dr. Sesta has been active in the research and development of case management for more than 25 years, and her research has included two funded studies measuring the effects of a case management model on congestive heart failure and fractured hip patient populations with measures of patient satisfaction, quality of life, and short and long-term clinical perceptions and outcomes. We thank you so much for being back here with us this morning. We invite you to kick us off with part four. Well, good morning. Good morning, Bev. It's part four, webinar number four. I can't even believe it, but here we are. And I love this group, Tony. You were so right about how great they are. I think it's my favorite webinar group we've ever done. I have to agree with that. So first, before we kick off this final webinar, I just want to give a shout out and a thank to Lindsay Kaysen who really makes our jobs so much easier and is so helpful behind the scenes and when we're on live. And Lindsay, just thank you so much for all the work that you do for us. I echo that, thank you. With all the polling questions we've given you, yes. And I also want to thank this, as you just said, Bev, this amazing group that, you know, while we're not physically in front of you guys, we do feel your energy and thank you for the heart. And we really appreciate your participation and your feedback, so thank you. Every bit of feedback we get, we use to make the next webinar just that little bit better. So actually, today is kind of a catch catching up because Bev has been extremely diligent through the last three webinars in keeping notes on things we needed to cover more about or things we didn't cover at all that you all were interested in. So today is, we're gonna talk about UM staff specifically related to case management in the emergency department but from a utilization management perspective and the same thing for clerical support. Bev and I help hospitals redesign their case management departments and one of the things we've been recommending for many years now has been the use of clerical support staff. So the professional staff, the RNs and social workers can work at the top of their license as we say. So we'll give you some tidbits on that and you know, it's low cost, high return on those kinds of positions. We'll also touch on physician collaboration again today and payer contracts. And then lastly, Bev has put together a study guide and we're gonna go over that as well toward the latter part of today's program. And I also wanna give a shout out to Iowa today because on Monday, I had the opportunity to speak with some of our participants. Well, it was one participant and her boss. I don't know if she's on today from Iowa and you know, what I learned from them, they're a critical access hospital in Iowa and from them I learned that every hospital has unique issues. There's some commonalities and then there are always those little things that are unique to a specific hospital. So it's sometimes, you know, we try to give a generic approach that meets the letter of the law and is compliant and all those things and then you got those little tweaks that happen in your own hospital. But if you follow the letter of the law and you, you know, make sure everything is as it should be, you can't go too far field, but this is a, you know, UM is a pretty highly regulated area. So, okay. I think I did all my shout out. Yes, sure. Well, I was just gonna say, we love all the emojis, the hearts and the claps and that's fun. Guess what? I figured out how to do it. Oh, good job. Okay. You wanna say? Yes. Is that you? No, clapping is gonna be me. There it is. Oh, nice. There you go. So I learned something. Good job. Oh, thank you. I got a thumbs up. Okay. So first of all, a couple of webinars back, you guys mentioned you wanted more information about how you could apply case management in the emergency department, specifically as it relates to utilization management. So we're gonna spend the next several slides talking about that. Before I get into the meat of it, I just wanna say, in general terms, we like to see both nurses and social workers dedicated to the emergency department. It should be the case. To the emergency department, it should be staffed like you would staff any other unit in the hospital with case managers. It is your major route of entry into the hospital and we must gatekeep it. So looking at why you want ED case management gatekeeping, we've talked about that a lot, particularly as it relates to the two midnight rule. But in general, you also wanna think not just as an entry point, but also an exit point because you will have those patients who can be, who the physician may potentially think can be admitted who actually might be able to be discharged or may be there in observation. In fact, there's a case study later on that exact point. You wanna move the patient through the ED. So eliminating barriers in the ED, getting test treatments and procedures done in a timely manner so that the time the patient spends in the ED is optimized. So if nobody's pushing those things, the length of stay for the patient in the ED will be prolonged. And then you just wanna make sure the patient's receiving medically necessary, appropriate and cost-effective care just like you would on the floor. So it's pretty much the same thing, just a twist for the emergency department. So expediting care, care coordination and facilitation, which if any of you have been with me in other webinars, we've talked about that quite a bit. Sometimes it's arranging for community resources. As I just said, patient coming in, patient going out, don't assume just because the physician says, oh, this is an admission. This is where you have to interject yourself, look at the case, talk to the physician and make a determination as to the correct level of care. You may have to suggest alternative levels of care that may not even be in the hospital or observation. So it's expediting as we said. One of the things I think we don't do as much as we could or should is communicating with the patient's primary care provider, particularly for patients who have come from their home and hopefully have a primary care provider. We wanna just get a sense of that patient and conversely let that physician know that their patient is in the ED. And then secondly, if that patient does get admitted to the hospital, then let the physician from the community know that as well. If the patients come from let's say a nursing home or subacute care, you may wanna also speak to those providers. So the collaborative process for you when you're trying to figure out what level of care this patient may go in and frankly, for those of you in those critical access hospitals, this may be a combined job with another job because you may just not have enough traffic in your ED to warrant a full-time physician. But somebody's gotta be available to work with the ED physician and the admitting physician. Everybody has a little bit different admission process in terms of which physicians decide who's gonna get admitted. Sometimes it's the ED physician or the ED physician makes a recommendation and that goes to the admitting physician or hospitalist. There's just all kinds of different ways. But you really wanna, this is the point in which you wanna make a strong decision about inpatient, outpatient and abed, which should be rare or observation. And then our social workers, they may be helping with discharge planning from the ED but also providing counseling for patients and families as well because they may be, particularly families may be in distress when they come into the emergency department. Okay, so review. So if you're gonna put a job description together, you're gonna review the medical necessity of the patient as I just discussed. You wanna have a list of criteria that are gonna bring certain patients to your attention, almost like a triage, right? So you wanna identify any potential 30-day readmissions. So there's usually a way to trigger that in the software programs you use in the ED. So a flag of this is a patient who was discharged within the last 30 days. You wanna give them attention to see if you can prevent that readmission and maybe there's another plan that could be used rather than a readmission for that patient. You should be considered part of the team in the ED. So if you're in a situation where you can't physically be in the ED all day, you still wanna develop a collaborative relationship. If you're in a bit of a larger hospital and you can have case managers and social workers in the ED throughout the day, then you need to feel that you're part of that team just like you would up on a nursing unit. Collaborating with the admitting physician once that determination has been made. You may need to contact the payer to help with facilitating that level of care. And then again, a resource to patients and families. Okay. So you're gonna use your criteria, whatever criteria set you use in your hospital to review. And this was one of the conversations we had, I had with my Iowa friends was about using our criteria early on when that patient's level of care has not yet been determined to figure out the right status. Use that as a tool to do that. And I know, we know that you may not always have all the information at the ready to do that. And that's why you have to have that conversation with the physician and collaborate with that physician. You may even get asked for a clinical review or clinical information. If that patient's been in the ED a while, if you're backed up and that patient's in the ED waiting for a bed. Oh, someone's having difficulty hearing. Okay. And then you wanna collaborate. If you have the triad model where you have a utilization management nurse, you have a case manager and you have a social worker, you wanna be sure you work very closely together. So on the clerical support side, as I said, we do know that these clerical support folks can do many things. They can do utilization management, some of the functions we're gonna talk about in a minute. But they can also do discharge planning functions, they can do compliance functions, giving out particular forms. Today, of course, we're focusing on utilization management. So this is not a clerical role where somebody's sitting in the office maybe working with a director. These are clerical support people who work directly on the units with the case management staff. So they would be assigned to the RN, case manager and social worker and work directly for them, doing anything on the list that they are allowed to do. Again, allowing the RNs and social workers to be able to work at the top of their license. So they can do, for example, they can send insurance reviews to payers if you need help doing that. Now, if you're in a software program, you can probably just do that as soon as you complete your review, but some of you may have different processes. They can obtain authorizations from payers for transportation, for DME, for the next level of care, even for medications. Now, these have to be very, very highly trained, if you will, folks skilled in talking with patients and families because there will be situations in which they must speak directly to the patient and family. So you just, you know, you want to pick the right people for the job. And lastly, our last slide on this this morning. So they might give the second important message. They might give the moon even. And of course, when the patient has questions beyond what they're able to respond to, then of course they defer to the professional, the nurse or social worker. And they can document authorizations, approvals and denials, if that's something you want to do. They can support and assist with your concurrent denial and appeal process, coordinating calls maybe with the payer medical director. So again, you know, somebody who's pretty competent and trained, but we have had no difficulty in our consulting life with finding people who enjoy this particular role. I'm just gonna see if I can turn my volume. I'm sorry, but I'm distracted by my volume is up all the way. Bev, can you hear me okay? Yeah, I can hear you okay. So I'm not sure what's going on. Yeah, okay. Cause I'm speaking into a microphone. And thank you, Jessie. So and supporting reimbursement certification and off. So, you know, you have to just think about all the things that don't require a licensed professional. That is really the point here. And then this, these people can be trained in how to do some of these things and really take some of that clerical work off the list of things that you guys have to do. All right, Betty, that's our ED. Okay, well, do you think that we should give them the little hint we learned about the title of the position and not using clerical? Well, I don't know if that was specific to that hospital. I'm not sure, but we have a gazillion. It would have been true in my hospitals as well. Yeah, so the comment that we had heard from one of our clients was that if you say clerical, if I'm getting this right, Bev, it's not highly paid. Was that the point or? Right, it's more of an entry level position. Yes, yes. Where the term assistant seems to elevate it in the HR world. Right, so case management assistant, case management associate. We have heard many different titles. So if you're going down that road, you want to use the right title, I guess is the point on that. Okay, so we promised physician collaboration, Bev, there you are. We did, we did do that. Our facility calls them post acute resource coordinator. Wow, that's a big title. Oh, interesting, that is. That is. That's a mouthful. That would limit, maybe they're not doing UM functions. But yeah, but I like the coordinator as a good term. Park, she says it's park for short. Aha. The ARC. I'm gonna call the park. That's interesting. Yeah. Okay, thank you for that input. It looks like there's, because I have the slides up on my screen, I don't see the chat all the time, but it looks like people are chatting. I know, I appreciate that. I love when they chat. I know, that's great. And I love when you tell me what they're saying. Well, let's talk physician collaboration then. Yeah, don't keep it a secret. Right. So one of the important things that case management leaders and case management staff have to recognize, and you probably do, is that documentation by our physicians or by our, the PAs or the APRNs is that their documentation is one of the pillars that does lead to reimbursement success. Now, we do know that in their educational programs, there's probably very little education linked to medical necessity, linked to even understanding what to do if you get a denial from an insurance company. And I think it's probably even more difficult from hospitals, for hospitalists, excuse me, that aren't in the office because those physicians, if you have surgeons, for example, some specialists who also have office hours, they may be a little bit more used to having to appeal a claim, denial, or a denial claim, whatever you wanna call it, but hospitalists don't always get that. And so it's really important, number one, that your medical director of your hospitalist group understands that. So documentation is not only a pillar, it's probably that singular issue that we're dealing with. That's why you as a case manager is going to go back to the doctor and ask if they have any additional documentation. And if they don't, you're gonna escalate it to the physician advisor. And not only is it so popular in having a denial, but that's how you win appeals is the strength of that documentation by the physician. So I think it's something that has to be addressed. We're gonna talk about strategies in just a little bit. So, well, here we are. We're gonna talk about strategies right now. So these are some strategies that you can think of. And probably one of the most important ones that kind of overshadowed is like the umbrella over all of these is you wanna be a colleague that understands the physician's perspective. So a real-time patient-specific conversation is so much more valuable than an email later after the physician's already seen six other patients. Also a very, very strong reason for those daily walking rounds at the bedside where the interdisciplinary team is together. Having an effective physician advisor role is so important. And then teaching when they're going to listen. So you may have that conversation during rounds, but maybe you need to do a follow-up conversation. Maybe they look perplexed or irritated on their face as you're talking to them, but maybe following up with that. And then- That was funny, that was funny. I'm glad you got that one. And then maybe even in the physician section meetings, keeping your education short and data-driven. So if you are in the orthopedic section meeting, let's say, and you're gonna talk about denials, or maybe you and the physician advisor are going together and you're gonna talk about denials, and they've had a large number of denials for one-day stays for total hips, one-day inpatient stays for total hips. We know that total hips, all the joints got taken off of the outpatient only, pardon me, the inpatient only, excuse me, list. But that doesn't mean if you're not on the inpatient only list that you can't be an inpatient, but you have to have documentation to support that. And so that might be a really good time to get them involved in discussing what are the kinds of things in their patients would they see that they seem to believe would be a criteria for saying that patient is going to be an inpatient. And then I think the other thing is we have to understand what it takes for physicians to be compliant. We're gonna talk in a minute about why physicians don't wanna do peer-to-peer review discussions with a payer medical director. And there's a variety of reasons for that. And that really comes into compliance just seems to be one more thing they have to do, even though we're not gonna get paid if they're not compliant. But it is just one thing on a very busy day where maybe they didn't sleep well last night, their teenage children were doing whatever teenage children do. I remember those days, but it's been a while for me. So it's important that I think we do, there are colleagues and we have to understand their perspective of this, but not give up on compliance. And then immediate feedback when there are issues. And one of the questions I would ask you and you can put it in the chat if you want to, but you don't necessarily have to is if you have a final denial for a particular patient, do you share that with your physicians? It's a strategy, I know it's a strategy that may involve executive level feedback, maybe your chief medical officer, maybe somebody doesn't want the doctors to know, I don't know, but you can't do better if you don't know better. And Tony, we use this in a client call yesterday, no news is good news. And so they're going to assume that if they don't hear anything from you that they are doing, as we would say in Oklahoma, they are just doing hunky dory. So it's so important for immediate feedback. And so we're going to give you an example of what a hospital did that we worked with. The physician, or excuse me, the hospitalist medical director was very engaged in the case management process and the medical necessity process and in the process of the hospital doing well and also patients not getting extra bills if there was something denied. And they were going to have to pay their part of the bill. So what this hospitalist group is, every Friday morning they would meet with the hospitalist medical director and they would have a weekly review already done of especially the Medicare self-denials or any physician issues leading to denials. So once a week they would sit down, they would discuss this and they would invite, identify, excuse me, the physicians involved. So we know that whether you're talking about a hospitalist group, whether you're talking about ED physicians, whether you're talking about surgeons, there may very well be more than one physician that's documenting in that medical record. And then I already mentioned admitting the, or including the hospitalist medical director. And then what would happen, interesting enough, is that hospitalist medical director would say, well, actually it was their, they had a nurse assistant that worked with them and she would send an email to the physician involved while we were in this meeting because we started the meetings with them. And she would send that information out to the physicians. And then if they had questions, then we could all respond in a timely manner. But here's the, here is the, what's the word I wanna use? Here's the great thing about- Oh, okay. Go ahead. No, I was gonna say here's the rub. No, I was gonna say here's the rub. Yeah, here's the rub. Yeah, but the great thing about this is those doctors just took care of that patient this week and they're going to remember them. Where if you're telling them two weeks later or three weeks later, and that may happen in a final denial by a commercial payer, Medicare Advantage, Medicaid Advantage, or plain old Medicaid. It may take a while for you to know, but in this process, they now remember Mr. Jones. They remember that he was a one-day stay. They remember why they expected it to be two days and they didn't really write the good documentation about why that patient ended up being discharged earlier when I, the physician, thought they were gonna be there for at least two midnights. And it was very, very successful and it spoke loud and clear to them. And then that we know, because we were around them for a couple of years, I believe, that that hospitalist medical director, if that kept coming up, that becomes a crucial conversation with that particular hospitalist. You could replicate that in the ED and you might even have other physician groups where that could be replicated because there's nothing like not getting timely response and trying to remember who Mr. Jones was when you've seen 98 patients since that time. Let's talk about the variables though when you're providing physician feedback. So if there's going to be a self-denial, we need to take an account if it's on a weekend, that doesn't excuse a denial, but if it was on a weekend, if it was on a holiday, if there was decreased case management staffing, if there's more than one physician involved in the care of that denial, we need to also understand those circumstances. It's not that we're going to, and I'm doing air quotes here, let the physician get by with a denial. That's not it. But I think we do need to understand that if there wasn't the opportunity to give available feedback, so let's say the patient comes in on Saturday morning, there are two case managers in-house when normally there's 12 or 14, or if you're in a critical access hospital, there's no case managers there, to ask for additional documentation, to escalate it to the physician advisor. That is a circumstance we have to really understand. We still want to get the feedback, but we can say, you know, we do understand that there wasn't case management support here. They're still responsible for themselves. You know, Tony, I did remember one thing when you were talking about the ED, and I don't even remember which hospital it was, although I can picture that ED because I shadowed the ED case manager down there. They were having so many denials in the ED, it was very busy, that they stationed a physician advisor down there. No, excuse me, they stationed a hospitalist. Yeah, they stationed a hospitalist like full time down there to deal with the admitting issues because we know that in most hospitals, you may have hospitalists on call, but they're going to be going back and forth between the ED, but this really was, they were able to capture some very positive trends and having that physician in the ED. The other thing, if I might say, the other thing we've seen is an admitting hospitalist, for lack of a better term, and that same hospitalist was, I don't remember that he or she was stationed in the ED, but they were there. They were- They actually had an office. Yeah, I do remember that, yeah. Yeah, so anyway, they were available to discuss these levels of care real time with the ED physician, because again, the ED physician, this isn't their focus of attention, let's face it. They're onto other things. So anyway, lots of different ways to, I was going to say, slice and dice. There are, there are. And like you were mentioning, there are, the compliance issues are the compliance issues, but I know that when we go to a hospital, we don't do a cookie cutter approach. We have to really look at what's going on in the hospital, what the primary issues are, what is really the executive team's area of focus, and then determine what the best model is, what the best process is for that hospital. So there's, like you said, lots of ways to slice and dice. Well, let's look then at the payer contract challenges. One thing that we know for sure, and I think we've mentioned it several times during this series is that our experience has been that most case management departments, from the leaders down to the staff, are not aware of what is in the contract. And we're not talking about, I think Tony mentioned this previously, we're not talking about what is your payment rate, and we don't need to know all the ins and outs, but we need to understand the reimbursement process. And so what we do in the reimbursement process. So everybody has different reimbursement schedules. And now we have found that most people get paid by the DRG by the case rate. But we found out as we were polling you that some of you do have some per diem rates for payments. So even for the same services, these payers have different rates. And then they have a wide range of network participation. So the plans are going to have different networks for post-acute care. They're gonna have different networks for a variety of things. So it's important that we understand what's going on and those requirements shift. And so what we find is that most of this is in the provider handbook. And that is not a part of the contract and the provider handbook can be changed. And we don't always know when an addendum or a change has been made until we get a preliminary denial or somebody from the payer tells us, okay, this is not looking like you're gonna be paid for that particular reason. Contract language is very confusing or can be very confusing and it's unique to each payer. And even the contract language that comes out of your managed care department out of that director or executive's mouth is not the same language that we need to see in the contract. So we're rarely included in payer contract negotiations and we don't necessarily need to sit in the room for the patient contract negotiations, but we need to have our feedback given to that managed care department so that they understand what we need. And one of the ways that is going to help is if they see the primary denials from this payer, that's probably gonna speak more loudly and more clearly to them than any other way that you might be able to get their attention. So they don't understand the need for the UM verbiage to be in the contract. And we've already said, we don't need payment rates, we need payment methods and then explaining your value. And that's where you could show them that payer one, here are the primary denials that we're getting for payer one, what we're getting for payer two, they may or may not be the same. Certainly we may also see what the Medicare Advantage plans and the two midnight rule that even though that the two midnight rule regulation is out there for Medicare Advantage plans and the fact that they have to use the inpatient only list and the fact that if they're gonna develop their own criteria, it has to be accessible. Those all while their regulations may be in the contract, we need to say that they're going to follow that even though who knows, they may or may not. Well, let's look at some of the verbiage that you want in that contract then. You wanna know what medical necessity criteria that payer is using. They don't have to tell you, well, I mean, they don't have to, but that's what we want is that they're gonna use minimum care guidelines, for example. And if they're using their own specific version of them, then we need to know what those are. We need to know how often we need to communicate with that payer. So is it a daily review that we're gonna be sending information? Is it going to be, we get a preliminary authorization for two days or three days or whatever. We need to understand what the communication will be. We need to understand if we can do a peer-to-peer while the patient is in the hospital. We know that some payers, and I haven't heard as much lately, but for a while we were hearing that some payers, if you do a peer-to-peer in the hospital, that's called your first level appeal. So we need to understand that. The peer-to-peer process, can it include the physician advisor? Absolutely, you want that. What the appeal process looks like, what the timelines are on that, so important. We need a notification upfront time when they're going to change the UN process. So if that payer is going to, let's say, they've been saying that we're going to pre-auth for five days, but even though we're pre-authing for five days, we want a review in the middle of that five days. I haven't heard of that, but I just made it up. But anyway, we need to have a 10 day notice or a 30 day notice or whatever it is when they're going to make a change. And then we need to understand if you want the payer staff to have access to the medical record or if you don't. And that is a varying, you know, there's pros and cons to it. We're not going to really get into that right now, but it's really something that needs to be well thought out ahead of time and decided. And then they need to understand that. So I think that one other thing that I wrote in, that I jotted down for myself, Tony, before I turn it over to you to start with the study guide is that you need to also understand what your state's department of insurance guidelines are for hospital payers, because there certainly are some discussions that can be done or accomplished with your state department insurance commission, depending on what the issue is, especially on repeated issues from the payer. Okay, Tony. Yeah, no, that's exactly right. I actually did that one time in New York. I used the New York insurance law, as you're just talking about, to appeal a case because I can't even remember the scenario right now, but it was outside of the legal parameters, whatever it was, you know. So sometimes you have to pull out all the guns. And I just want to put a, you know, a exclamation mark on what you said about perhaps asking for a peer to peer, maybe your first level review. That is, you know, those are the kinds of things like you just went through that you really need to know. And so when we hear from you guys that your finance department or your managed care department, whoever does your contracts, doesn't want you to see the contract. And we say, we don't want the whole contract. We just want the UM portion of the contract, because these are the kinds of nuances that are very specific sometimes to a particular payer that you may not even know exist. So I just wanted to put a dot on that because that's important. All right. Now to our study guide. Yes, we gave Lindsay a run for her money in polling questions. So how are we doing this one with multiple questions? I think it's just a, you know, I think you can tell them what it is or they can put it in the chat, either one. Okay. So this is going back, I think, to our first webinar in this series. Yeah. And we all have to think back to four weeks ago. Utilization review is a watch process. Utilization review. Continuous, one answer. Anybody else want to venture a guess? Oh, whoops, I'm sorry. Okay. So utilization review is a passive process. Thank you, there, Heather got it. Okay. It's a passive process, passive, meaning in the back of the day when we would do a review, you know, we were kind of just doing it. We weren't really actively acting upon it. So then utilization management is an, there's a clue, blank process. So that's active. It's dynamic, too, but yes, dynamic and active are similar words. So yes, utilization management is an active process. So it's a process of measurement that compares the severity of a patient's illness and care needs against accepted criteria to identify what? Anybody? When you do a clinical review, thank you, Joanne. There's Joanne. Hey, Joanne. Hi, Abigail, thank you, guys. Yes, medical necessity, remember? Oh, they're waking up, Tony. Hi, Joanne. Yes, so when you do a clinical review, you are trying to see whether or not the patient meets medical necessity. When a case manager is asked to do a clinical review, the patient meets medical necessity. When a case manager assesses the clinical, something just popped up, okay. When a case manager assesses the clinical picture of the patient and the documentation in the medical record, the review is called a blank level review. Yes, thank you. First level, first level review. Excellent, thank you, thank you, thank you. Okay. All right, next question, everybody. When a case manager consults a physician advisor to review a record with an inpatient order that does not appear to meet medical necessity, this review is called a what level review? Secondary, yes, Marsha, thank you. Secondary, secondary level. Thank you. A non-physician can always make the determination that a medical record does not, okay, that a medical record does not meet medical necessity. A non-physician can always make the determination that a medical record does not meet medical necessity. So for this one, you can answer like we did last time. Several of your responses are coming in. One question while you all are putting in your response here that came in that asks, where would you find the state insurance information? Oh, I just looked it up online. Yeah, just Google, like the Georgia State Insurance Commission. Right. Should get you there. And there's also, you can call them too if you, because the law can be a little thick and difficult to understand. You can always call them and they're very helpful. And I'll say too that if you're joining as a member of GHA, you can always reach out to us and we can put you in contact with the appropriate person. And I'm sure that is the case for other states joining us with your hospital associations as well. That's a really good point, Lindsay. Yes, thanks. Yeah, that's great. Okay, we've gotten some good responses. There are those results. Okay. Okay. So can a non, so a non-physician, usually an RN or any other non-physician cannot determine medical necessity. Okay, that has to be a physician. So 91% of us got that one right today. Thank you. Okay, one moment here. I don't know what you're leaning on. No, remember there's a magic trick. Oh, okay, but we have to go back up one. Oh, I'm sorry. No, my bad, my bad. I'm sorry, I was holding the phone in my hand. Okay, so here we are. We have a case study now. So let's walk through this. And Bev, I had to look, oh no, this isn't the one. One of them I had to look up the value that you had. I know, I did too, I did too. You're not alone. How bad it really was. So a 69-year-old patient with a managed Medicare Advantage payer came to the ED on May 20th with abdominal pain, nausea, and vomiting. Abdominal pain, nausea, and vomiting with a white count of 6.2, negative urine, glucose 197, potassium 3.4. Test X-ray shows no acute findings. CAT scan of the abdomen and pelvis, no acute findings. Patient's diagnosed with gastroenteritis and hypokalemia. The patient gets IV fluids, IV Zofran, and his NPO. The next day, the 21st, symptoms resolved and tolerating oral intake. Patient is discharged for outpatient follow-up. The payer denied observation service due to, quote, no clinical criteria or diagnosis that met the CMS criteria for observation level of care. And I guess they referred to the Medicare Benefit Policy Manual. That's true, and this is an actual case, but if you look at the CMS Medicare Beneficiary Policy, there is no, I don't know what criteria for observation level of care. What CMS talks about is what you're going to do during the observation level of care, and you're going to observe the patient. They've got signs and symptoms. So this actually, in the green, comes from what they said. Right, right, and I think the most salient part of that is the underlying part. Observation services are commonly ordered for patients who present to the ED and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge, which is exactly what observation is. So that is a good thing to use to appeal because this patient was like a classic observation patient, if you ask me. My gosh, yes. Yeah, right? Okay, next slide. The payer stated the patient could have been safely and effectively treated in a less intensive setting of care such as the ED, and observation level of care was not medically necessary for this patient at this time. So would you appeal this denial? I think we kind of gave away the answer already. My hair was on fire. Actually, one of you all, one of y'all, one of all y'all sent this to us. So we actually used your example. It was Joanna, it was Joanna. Joanna, yes, we can't even believe this payer would be this whatever. Silly. They were grasping at straws. Yeah, I mean, come on. Yeah, and some pretty consistent. Yes, I said petty. Yeah. Absolutely. Okay, there are those results. Okay. Yes. Absolutely. Couple of people said no. That's interesting. It wouldn't appeal. Okay. Okay, so since most of us are going to appeal, Bev, let's discuss the process for your appeal. The payer did offer a peer-to-peer form for a peer-to-peer request. Put in the chat your reasons for this appeal for those of you who decided you would appeal. And I think, you know, you pointed out in that green there's nothing like giving them Medicare verbiage right back to them using their resource. Oh, exactly. Absolutely. So, yeah, that is interesting. You gotta pull out all the guns sometimes. Yeah, use that, use the law, use whatever you have to use. Exactly. And who wants a patient in the ED observing them? I mean, that goes totally against some of our value-based reimbursement looking at time patients are spending in the ED, so. That's true. I don't know. Joanna, you better, we know you guys are gonna win this. Okay. Abigail had a, so Abigail is saying electrolyte imbalance, unable to tolerate oral intake initially requiring other fluids and medication. Stephanie, the patient requires IV fluids due to NPO status, unable to tolerate PO intake, repeat labs, something to electrolyte imbalance. Patient requires short-term treatment and clinically appropriate services to treat electrolyte imbalance. So most of you are focusing on the electrolyte imbalance piece of this. So you wanna get those electrolytes more normalized before you would release that patient. Patient required short-term treatment and clinically appropriate services to treat electrolyte imbalance. Did I reread that one? Marsha, thank you, Marsha. Are there any above, Lindsay? Let me see. Okay, Allison says, we would start with a peer-to-peer. However, we would use the criteria stated on your screen for appeal. Absolutely excellent, thank you. So, Joanne, we wrote your appeal for you. There we go. Okay. All right. Next. Another case study. You're welcome. A traditional Medicare patient is scheduled for surgery tomorrow morning. Should you review the orders before the surgery? That's not a... We don't have that as a polling question, do we, Lindsay? It is, yep. Oh, okay. I didn't see it. You know what? I have it up on my screen, but I didn't hit launch. There it is. Oh, there we go. Okay, there it is, okay. It took a second for it to think about it. Okay. All right, a traditional Medicare patient is scheduled for surgery tomorrow morning. Should you review the orders before the surgery? Look, we have a pretty resounding response here. All right. Oh, it is a resounding yes. But I'm going to say, if you have... I was going to say, if you have the orders, you know, so some of you don't get those orders necessarily ahead of time. There's a second part on that slide, Beth. Yeah, I know. I did my magic trick, and now here we go. All right. Now here we go. Okay. As you are reviewing this patient's orders, you see a patient has an order for surgery that states, Admit for observation after surgery. What are your concerns with this order? A, an order for observation service should never be placed before a surgery. B, the use of an order for observation service can only be used if a patient will likely be admitted as an inpatient after surgery, or A and B. And this is, again, ambulatory surgery. I don't think it says that. Let's see, and same with your response. Can we give you just another couple of seconds here? This is a tricky one, kind of. It is kind of. I mean, a lot of questions are like, okay, well, what if, what if, but. Yeah, I know. Give me just another second, I see a couple more still coming in. Okay. Nice. 82% of you said the correct answer, which is A. We talked a bit about the fact that the physician should not automatically write an order for observation service after surgery because the determination as to whether the patient would go into observation would be based on the patient's clinical condition following their recovery period. So an order ahead of time, and frankly, B doesn't even make any sense to me at all. I know. I know. But you know. The use of an order for observation service can only be used if the patient will likely be admitted. So no, that's not correct either. So the answer would be A. Okay. All right. One more case study here. If a Medicare, and that could be the traditional Medicare patient or a Medicare Advantage patient, has an inpatient order but the medical record documentation does not support inpatient medical necessity, the first step by a case manager is to A, call the physician advisor to initiate a condition code 44, request that the attending physician change the order to admit to observation, B, contact the physician to see if there is additional documentation that can be added to increase the likelihood of medical necessity being met, or D, pull a code red. I'm sorry. We have to have a little humor. Okay. We have a good response here. Share that result. All right. All right. Ninety-seven percent of you said contact the physician and ask for additional documentation. That's your first line of defense, always, always, in this kind of a scenario. I'm just trying to... So the first step would be contact the physician. After that, there's other things that you might have to do, like calling a code red, for example. Just kidding, just kidding. Okay. Next one. If a Medicare traditional or Advantage patient has an inpatient order, but the medical record documentation... Oh, wait. Oh, no. ...does not support the medical necessity for an inpatient order and the physician has no... Okay, so the physician has no additional documentation to provide. So you've talked to the physician. He says, I got nothing. What is the second step by the case manager? Call the physician advisor to initiate a code 44. B, request the attending physician change the order to admit to observation. C, contact the physician advisor to review the record. Or D, call a code purple. Well, code purple in my last hospital meant that you needed security immediately to help. You might want to call some code purple some days. I see a couple of you still put in your responses. I'll give you just another second here. Okay. Okay, we'll end that and share those results. Okay, 82% of you. 82% responded with contact the physician advisor to review the record. So that is the correct answer. You want to do your due diligence before you start thinking about condition code 44, changing orders. I don't think that you can just change the order. So the correct answer is... Well, go ahead, Beth. Well, I was just going to say, if we go back to, I think probably the second webinar when we talked about compliance and the conditions of participation, it does say in there that a physician, I believe it's in there and then also a memorandum, I think we gave you that, a physician cannot just change an order back to observation in a Medicare patient. Now that's not true for Medicare Advantage. It's not true for commercial plans, but for traditional Medicare, you can't do that without the physician advisor talking with that physician. And then that physician is going to say, I agree with the UR committee, because that physician advisor represents the UR committee. So I'm sorry, I interrupted you, Tony. No, no, that was good. That was good clarification. But I was going to call it code purple anyway, but okay, fine. Okay, well, that might be, yes. If a physician advisor reviews a record with an inpatient order that does not meet medical necessity, the physician advisor should first, A, change the order to observation service, B, discuss the case with the attending physician to better understand why the inpatient order was written, C, explain to the attending physician that the order is wrong and that the patient must be discharged, D, request that the case manager contact finance and ask them to bill a condition code 44. Looks like we're getting a pretty consistent response here for this one. We'll give it just another second here. There's that one. Excellent. 96% got selected B, which is correct. So at this point, you're going to have the physician advisor talking to the attending physician to get the attending physician's point of view and what the plan is and why he admitted that patient. Okay, excellent. We're going to move on to another one now. Oh, this was the lipase that I had to look up. I also had to do that. It looked like a big number, but... I know, but it could be deceiving, so I wasn't sure. A 30-year-old male was seen in the ED with upper abdominal pain, tenderness, and nausea. His labs show a lipase of 1,477 and a CAT scan showing changes consistent with acute pancreatitis. His medical history included hypertension, anxiety, depression, GERD, and alcohol use. Well, everybody has all of that. I'm kidding. He was admitted as an inpatient. Doctors treated him conservatively with these orders, NPO, IV fluids, pain management, and antiemetics. The patient was discharged the following day after tolerating a clear liquid diet and improvement of symptoms. His insurance denied his admission as an inpatient. Would you agree with the denial? Would you agree with the denial? That question's up there now. Thank you. Right, I see a little bit of a split here in this response. I'll give you just another second here. Sure. Okay, so 31% of you said, yes, you would agree with the denial and the 69% said, no, you would not agree with the denial. So, I think on this 1, I think this 1 is kind of interesting because we know that a lot of commercial payers on short stays are only going to pay observation service, you know, they're going to deny the inpatient. And so, I think this is a great discussion with the physician advisor saying, is this worth going head to head with the payer to say, look, this patient met medical necessity, if it did indeed meet the criteria. I would say that probably what my experience has been, and Tony, what we've seen with our hospitals is, we don't have to agree with the denial, but we may have to accept the payment. I think sometimes that's just what happens. So, this is a, I don't know that there's a right or a wrong to this 1 and it may be based on who the payer is, what you're going to do. So, it's just an interesting conversation to have. Yeah, I mean, the conservative treatment, the quick response to treatment, you know, I don't see this as an inpatient. I see this as an observation patient, personally, and I don't see any really, you know, intense, you know, acute requirements for an inpatient admission. I just don't see it myself. I would have to go through the criteria set, of course. Yeah, I think that's it. I mean, pancreatitis, I mean, vital signs, et cetera, et cetera, the life pace. So, yeah. Yeah. Okay, so if you disagreed with the denial, what would be your next step? A, ask finance to write off the charges. B, pursue a condition code 44. C, ask the attending physician to put verbiage in the discharge summary that would make the case meet medical necessity or D, request a peer-to-peer review from the attending physician to the payer medical director. I think we have just another second to read through those options there and select the response. I'm debating between two myself, Bev. Well, just remember the patient is 30 years old. Right. So, I think that may be one thing that might help us a little bit, but yeah, I don't know. Okay. Let's see what everybody else thinks. Yeah. Okay, let's see what we got here. Well, this is interesting. 85% answered D, request a peer-to-peer review from the attending physician to the payer's medical director, which was initially my answer. But, Bev, I changed my answer to B, pursue a condition code 44. I wasn't sure if the patient was still in the hospital or not. Yeah, the condition code 44 is really for Medicare patients, though. Oh, what was this? He's a 30-year-old. Oh, oh, oh, oh, that was the trick. Gotcha. I do think that this does say, you know, compliance is not always black and white, some of it, especially the medical necessity piece. And what we think is medical necessity versus what maybe even a physician advisor thinks or a payer. And, you know, that's why we do these case studies in these questions, because I think it gives us an opportunity to really talk about these challenges that we deal with. Absolutely. It's a good thing I don't do appeals, because, well, I guess I would have looked a little more closely than I am this morning. Well, exactly. And you would have known who the payer was, et cetera, so. Yeah, yeah. Oh, thank you, Abigail. Per Millman guidelines, a lipase, oh, it popped away. Hang on. So the over three times normal qualifies. Over three times normal. Yeah, so I didn't know that. Thank you. So a lipase of over three times normal qualifies as inpatient. And Stephanie said something similar. Inpatient criteria was met at admission per Millman with lipase three times. Okay, I did not know that, obviously. So, yeah, so then that peer-to-peer would be appropriate. Okay, thank you. Okay, next case study. Key points for a physician or a physician advisor during this peer-to-peer discussion. Oh, see, the answer was on the next page. Well, Bev. Focus is on communicating the medical reasons justifying the inpatient level of care for the short length of stay. So discussion of the patient's medical complexity. Some of you have already said that. Use of IV opioids, close monitoring, discussion of elevated lipase greater than 10 times normal, positive CAT scan findings, and history and physical exam consistent with acute pancreatitis. But it sounds like the linchpin in this was the lipase, if I'm not incorrect. Okay. We love these responses. Yeah, smart group. Peer-to-peer discussions with the payer medical director. So let's just talk about how we can optimize that process. So there may be nothing in your contract. If nothing is there allowing you to do this, you should be able to do a peer-to-peer during the hospital stay. So if it's silent, if the contract is silent on this point, I would go for it. Peer-to-peer reviews can occur at two different time frames. So when the denial is presenting during the hospital stay, you can do a peer-to-peer. Or when you get the denial after discharge. I think we tend to use it more while the patient is still in the hospital when you get a concurrent denial. But you can do it afterwards as well. Determine if the contract with your payer allows peer-to-peer review during the hospital stay as some only allow a peer-to-peer review after discharge. You know, that's to their advantage because, you know, after the horse has left the barn, you know, allows a care provider other than the attending physician to do the peer-to-peer discussion with the payer medical director, for example, advanced practice professional or physician advisor. So if we're at the table during these contracts or even if we give the folks who do the contracts the criteria that we think should be in the contract, at least it gives them something, you know, a template. Because honestly, they may not know how these smaller nuances will affect us. And so there's often no speaking to it. Or if it is in there, you don't know what it is. So, you know, either way, we have to have, particularly you leaders today, have to really, you know, force the point on some of these things that are either silent or are specific, but you don't even know. Okay. Can I add one thing? Just for you critical access hospitals, it would probably be really helpful if in your contracts you did have something about an advanced practice professional doing peer-to-peer reviews. Some of it's going to depend on if they, you know, more and more we're seeing, I know in Oklahoma, this is coming up that advanced practice professionals do not have to have a physician oversight. It hasn't passed, but it's in the legislature right now. If that is also a part of your hospital, your medical staff bylaws, and that might be true in a critical access hospital where you have both hospitalists and advanced practice professionals seeing the patient, but maybe not a hospitalist in-house every day. There might be some value in that. So, just a thought. Yeah, thank you. All right. So, what if your physicians refuse to do a peer-to-peer review with a payer? Does the physician believe the patient should be inpatient? So, this could be viewed as a professional issue. So, use your physician advisor. Request that your physician advisor explain the importance of a peer-to-peer if the documentation in the record and the review by the physician advisor indicate medical necessity as an inpatient. The physician advisor can submit a peer-to-peer review with many payers. So, again, I think the majority will allow the physician advisor to do a peer-to-peer, but some may not. So, how do you know? Right, Beth? I mean, you got to know. Exactly. And if the refusal continues, you're going to escalate it to your leader. Okay. Why don't physicians want to do peer-to-peer reviews with a payer? Well, I think we've touched on many of these. They're too busy. You know, well, surgery is less likely for this scenario, but it's possible. And they're in the OR. I've seen that. Don't know what to say. So, they're like, I don't know. It's not their job. They were never mentored in the process to do a review or no physician leader has let them know this is expected or all of the above, you know. So, it does require physician leadership. You know, maybe it requires some education. That's why sometimes, you know, we turn to the physician advisor for any of these particular reasons. So, you just want to make sure that's okay with the payer. Okay. Next one. Case study with a slant. All right. This is a long one. A 30-year-old male. It's actually just, I'll just let you know, it's exactly the same guy before. Yeah, we talked about. All right. So, yeah, go ahead. No, it's what if it was 66-year-old? Yeah, right. Okay. So, we had our 30-year-old guy who, as it turns out, qualified for an inpatient stay because of his light pace. Yay. What if this were a 66-year-old traditional Medicare patient? Would you self-deny this short stay? Do you have that as a question? Oh, great. Yes. Yep. There it is. Thank you. Okay. You were, like, right on today. Thank you. She's right on every day. Well, she's had to be right on a lot today, but yes. That's true. More to come. Yeah. I don't know if you saw that comment there in the chat, Dr. Sesta, from Lynette that says, with appeals, we make a denial prep sheet for our providers. We tear apart the chart and review all documentation, labs, vitals, what they re-admit, risk, and so forth. So, it's a lot of work. It's a lot of work. We tear apart the chart and review all documentation, labs, vitals, what they re-admit, risk, let's see, what re-admit risk they are, and then give them tidbits, verbiage, reviewing every day. We make sure to tell the doctor what we are appealing. And if we don't get a return to this denial, we will only get 48 hours. We're trying to get a skilled nursing facility care approved. Okay. That is great. Thank you for sharing that. Wow. Yeah, that's good. Okay, we've got some good responses. I will share that. So, what if it were a 66-year-old traditional Medicare patient? Would you self-deny? So, 78% of you said no, you would not do a self-denial. And 22% said yes, you would. So, considering the lipase and all of that, I think, Bev? Yeah, I think, yep. We would keep this, right? Yep. Okay, I got to get out of here. Don't go ahead yet. What should the physician have documented in the medical record regarding the patient's discharge after one midnight? A, the patient recovered quickly. B, the patient recovered more quickly than expected with recovery summary. We're getting a pretty resounding response here for this one. Great. Okay, share that result. Oh, I got it right, too. Thank goodness. Okay, so patient recovered more quickly than expected with recovery summary. Excellent. Thank you. And now, it's time for the two-midnight rule. Don't we all love the two-midnight rule? The two-midnight rule is applicable only to Medicare Advantage patients, true or false? Do we have this? It is, but it's kind of frozen here. Let me see if I can try that. Well, you all might have to type your response here into the chat for that one. It's not letting me launch it for some reason. It's like it's frozen there. Aha, well, that's okay. I'm seeing lots of B for false. Yes, they're right on target, aren't they? Yep, they are. So, of course, the two-midnight rule recently became applicable to Medicare Advantage patients, but it has always been applicable to traditional Medicare patients. Oh, I think I just answered the next one. So, okay. Okay, so we don't need the next one, yes. Yes, so I'll just read it. The two-midnight rule applies to Medicare Advantage plans the same as it does to traditional Medicare patients. Okay, excellent. Yep, so let me do that one here. Yep, that's everybody saying that response. Yep, mm-hmm. Yep, all righty. Okay, thank you. Are Medicare Advantage plans obligated to make their medical necessity criteria publicly accessible? Just another couple of seconds here. Okay, 86% said yes, which is the correct answer. So, you know, it's interesting to me, Bev, and I don't know if you have a sense of how many plans have their own criteria, you know, and you got to ask yourself, why would they do that? Oh, because they can hide it and just say, it's our criteria, we're going to deny, yeah. And how do we know it's valid? Their criteria is valid, you know, actually, and you know, Dr. Hurst said that this part of incorporating it into the two midnight rule for Medicare Advantage plans was so that they couldn't get away with, I can't remember the exact verbiage, because he's pretty upfront about this, but they can't get away with hiding why they're going to deny a patient. Yes, yes, that makes perfect sense. Exactly. Okay, are you ready for me? Is that my turn? It's been your turn all along. Oh, shoot. No, you think, no, I'm kidding. You're good. Go. Well, you know, I just want to mention to you all that, you know, one of the reasons we do this is so that you have a chance to go back and we talk about what we learned, but like we've mentioned before, so you can see what other people are doing. Lastly, so you can validate that you are doing some of the right things, and maybe you're doing all of the right things, but we learn from each other so much. Well, a little bit more about the two midnight rule. According to it, physician documentation requirements for an inpatient order include which of the following? So, the expectation of an inpatient length of stay to be at least two midnights. Documentation of the reason for hospital services for any patient order must include medically reasonable and necessary care, and they also must discard or they must discuss the discharge plan. So, or all of the above, or just A and C. We already have a good number of responses in. I'll wait just another second here. I see a couple of you still putting those in. Okay. And here are those results. Okay, you got it. Definitely it is, there were three of you that said expectation of the inpatient length of stay to be greater than two midnights or greater, but they also have to have medical necessity. And kind of interesting was that when CMS put the original two-minute rule out, they said, we are not talking about Medicare, or we're not talking about Interqual or Milliman Care Guidelines or Change Healthcare or whatever we wanna call it now, but we are talking about the physician's picture of the medical necessity of the patient. But yet we do still find that payers are using that term medical necessity and not meeting medical necessity. And they are supposed to discuss the discharge plan, which I would guess most physicians do, but maybe not all. I don't know about that, Beth. Yeah, I'm not so sure about that one. As that was coming out of my mouth, I thought, okay, don't be stupid. That is, that's a- No, you're optimistic, that's all. Yeah, okay. The timing of an inpatient stay for billing purposes. We're just gonna go back to this for a minute because it's a little bit different than any other hospital stay. So any other hospital stay, if the patient stays one night in observation and one night as an inpatient, that's a one-day stay for them. If they say one night, let's see, two nights in inpatient, then it's an inpatient. But the two midnight benchmark clock begins a little bit different at a different timeframe. And it really starts when the patient receives hospital services. And this is the CMS verbiage. This can include the start of care after registration and initial triaging, so that initial part is done. And then they might do an initial triage and put the patient back out in the waiting room, but that clock started after initial triaging. Observation care, ED, OR, other treatment services. So how many days inpatient does this patient have? The patient came in the ED at 11 p.m. Wednesday with an inpatient order, but wasn't moved to a hospital bed till 2 a.m. on Thursday. And then they were discharged on Friday. How many inpatient days does this patient have? And you see those options there on your screen, one day or two days. Give me just another couple of seconds here. Okay, there you go. Okay, and it is two days, because even if the patient's in the ED, when that order's written, when the time began. So, you know, for example, if you have a, let's say that patient, there was no beds, and that patient stayed in the ED for four nights, and then was discharged from the ED, that's still a four-day inpatient stay. And Tony, I think you mentioned before that it's imperative, though, that we provide inpatient-level care to that patient. So that's why we, you know, you want to get a ventilator patient out of the ED as soon as you can. But even if it's an observation service patient, we still need to be providing that observation service level of care. Okay, just a second, I gotta get my little, okay. Now let's talk about a patient with a little bit different timeframe. So that patient came into the ED, and we're talking about Medicare beneficiaries here, at 4 p.m. on Wednesday with an order for observation service, but wasn't moved to a hospital bed till 2 a.m. on Thursday. And then on Thursday, the inpatient order was written, and the patient was discharged on Friday. How many inpatient days does this patient have? A couple still put in your spot, so I'll give you just a 2nd. Okay, this is a tough 1, because on the 2 midnight rule, you roll in. The 1st observation night to the 2nd inpatient night and then it's called for the purposes of the 2 midnight rule. It's called a 2 day stay. So if your QIO is reviewing your records, you would have 1 day stays as inpatients reviewed and 2 day stays as inpatient reviews, and this would be considered a 2 day stay. It's not anything that's going to change anything you do. It's just one of those confusing things that we thought we would add in because that's that's kind of how the how the how it's sliced and diced. Tony, as you would say. Yeah. OK, let's bring a. At 4 o'clock on Tuesday, a 75 year old Medicare patient with chest pains placed in a hospital bed with an order to admit. Cardiac enzymes are negative. EKG is unchanged from testing before admission and the pain is resolved. But at 5 o'clock on Wednesday, so the next day, the physician making rounds decides to keep the patient hospitalized for treadmill testing on Thursday. So keep that in mind because we're going to talk about this patient again in just a little bit. But the order said admit didn't say admit as inpatient, didn't say place an observation service or anything. It just said admit. So if the order is to admit, the case manager gets to decide what the physician really meant. Did that physician really mean inpatient or observation service? So do you agree that that case manager could make that decision? True or false? See a consistent response here. You know, every time as soon as I say that it turns out not to be consistent. Okay. Well, probably there was some deliberation. Exactly right. Yeah. Especially if there are several of you in a room and you're deliberating over what you want to, what the answer is. Okay. So actually you don't get to choose. So good job. False is the answer. Although we used to. We used to get to choose, but that day is gone. Okay. The case manager, so now we're still talking about our Medicare patient that came in pretty much negative for cardiac what we're seeing, but the case manager clarified the physician's intent was admit as an inpatient. And we know that when Medicare sees the word admit, even if you say admit to observation services, they are going to assume that you mean inpatient. That's just the way the ball bounces with CMS. And so the, so the case manager said, okay, well, do you have any other documentation? And there's no further documentation. We've asked you this about 14 different ways, but what is your next step? If the doc, if the doctor has no further documentation, ask the physician to change the order to observation service, use both interqual and melamine care guidelines to determine whether the order should be inpatient or obscure or ask the physician advisor to review the record. And hopefully using Lindsay's term, we should have resounding response on this one. I'm not even going to say it yet. She's mom. She's not saying anything. Just in a couple of seconds, see a couple more responses still coming in. All righty. Okay. There we go. Okay. Close to resounding. Close. Very much. Yes. So the next step, you should have used interqual, you should have used your medical necessity criteria before you went to talk to the doctor. And so now you're no additional documentation. So your next step would actually be to go to the physician advisor to review the record. So. Okay. The physician advisor. So you do go to the physician advisor. They agree that an inpatient order doesn't meet medical necessity. They contact the physician advisor recommending an order for OBS. So this is where we get this out of the conditions of participation and some of the clarifying memorandums that we've received from Medicare. If the physician agrees with the physician advisor, what should that position do? Should they change the order to OBS? Or should they change the order to OBS and mention that they agree with the UR committee and the medical record? Or should they contact finance to just write off that bill? If you're saying to yourself, how many times can they ask, how many ways can they ask the same question? A lot, but I think 1 thing, this is really your foundation for medical necessity is the getting that process and being consistent in it and doing it every single time. And the other thing that I think we mentioned before, but we haven't mentioned today. I don't believe is when you are going to go to the physician advisor. That shouldn't be a surprise to the physician. The idea is I asked you for more documentation. I don't have any more. Okay. I'm doing my 1st level review. I'm going to escalate it to the physician advisor who may see something that I'm missing in here. We are actually 5050 here on this 1. Oh, that's well. Here's the here's the thing changing the order to observation service. That's what the physician needs to do. But that 2nd, part changing the order and mentioning their agreement with the committee is what is in the conditions of participation. So, that is and so what we see in many hospitals is that there'll be a drop down order that will say for Medicare traditional Medicare patients that I change the order to observation services. I have spoken with the committee and I agree with them when we started out having to do this. Then it was such a challenge because the doctor would say, change the order to observance. Then we'd want the doctor to write that in the. So, we have found over the over time that that drop down order is so very helpful and then you can instruct the physician to use that one. But thank goodness nobody just told finance to write off the bill. So, that these questions I think do bring us to some good conversation. Okay. Still the same patient. Still, no other, no other documentation. The position advisor talks to the doctor. The doctor writes the order observation that he agrees with the committee. If the patient has not been discharged, which billing code would be applied to this patient's bill a code 21 provider liable W2 or code 44. You know, Tony, when I started out as well, I started out as an ICU nurse, but when I ended up in the case management area. I never thought that billing codes be a part of my day to day vocabulary. That is so true. Okay. There's that result. Okay. Yeah, it is. Well, let's wait let's condition code 44 is right. But let's go to the next. Okay, here we go. Let's go to the next question. What's the determining factor for which of those codes should be used those billing codes. The patient still in a hospital bed and hasn't been discharged, or all of the symptoms that brought the patient to the hospital or resolved. Which one of those determines if you're going to do a condition code 44 or that code 121 provider liable. Looks to be about the same percentage-wise here, just to... Okay, nice. And that is exactly right. The patient is still in a hospital bed and hasn't been discharged. So, good response there. Okay. If a Condition Code 44 is billed, which one of these is provided to the patient? An ABN, Advanced Beneficiary Notice, a HIN, a Hospital-Issued Notice of Non-Coverage, a MOON, Medicare Outpatient Observation Notice, or a Denial Letter. And as you are putting in your responses, let me just remind you all as we have about 15 minutes or so left in our appointed time for today. If you have any questions that maybe even from our prior sessions, you want to go ahead and be typing in that you just haven't asked yet. If you would go ahead and type that into the Q&A option or if you don't see that you can of course utilize the chat and type in your question there as well. So we can make sure to have time to address those and before we conclude today as well. Hey, there's that result. Okay, it is the moon. ABN is for an outpatient. So, like a Medicare beneficiary traditional Medicare patients going to go to lab, and there is a possibility as an outpatient that Medicare might not pay for that lab let me give you an example like a lot of testing that's done, like cholesterol, etc. can only be done so many times a year, unless there's specific documentation by the physician so there might be you, a patient will sign an ABN, and that says okay I agree that I will be responsible for the, for the charges. And then the hand is a hospital issued notice of non coverage that's given when a patient is in the hospital, and they're no longer meeting medical necessity and Tony went over the several different kinds of those hands that can be delivered but the moon is okay So, on the condition code 44 we've moved you from inpatient to outpatient observation. Pardon me, and we need to notify you that you are an observation service patient. So, that is how that goes. I hope none of you that are case managers out on the unit, doing your discharge planning care coordination resource management and even if you're doing um, and you're out on the unit that you don't have to build the observation hours, I am telling you, I fought to the nail. When this process first came out because this is this can be time consuming but it's also pretty cut and dried, and maybe you case managers that are doing, you are, are, are doing observation hours I'm not sure how that works. But anyway, let's just talk for a minute about how this works. So the 75 year old man comes in observation service at four o'clock on a Tuesday we already talked about this negative pretty much cardiac wise but at 24 hours later, can we just say this is a Medicare They came in at four o'clock on Thursday. The next morning, he is one of our priorities, it's a sense of urgency. Does he stay or does he go. And so I know you can always have that conversation every morning with every position but that would be the best practice. So you don't have the physician coming in at five o'clock and making rounds and decided, keep the patient hospitalized for a stress test on Thursday. So, what should the billing for the number of observation hours stop so we see that the pain is resolved, everything is negative. When does that stop. When the EKG is unchanged the pain has been resolved and the need for continuing monitoring stops. That's one observation service our start stop. So, whatever time in that record that that patient stopped being observed and monitored is when those observation hours stop. So, I just, that's the observations period it's past, and that patient literally now doesn't have any more monitoring for observation hours, you can, you'll have to talk to your finance department, but I do believe you probably are can do that I mean it's just better if all the symptoms are gone get that patient out, especially if you're desperate for beds, which sometimes does happen. Okay, let's talk about a few denials here and we're winding down. Um, is the case management department do they cause the most medical necessity denials. True or fault is a true fault. I'd like to know. It doesn't show the options there but choice one would be true and choice two would be. I'm not sure it shows up like that. Does the case management department cause the most denials. Nope, I am going to say it. It looks like we have a resounding response. Well, they're not going to take the blame and I think they're right. I hope they're right. I hope. Yeah. Okay. Now that is resounding. You know, we at the very start of this early on, we talked about that physician documentation is probably the key to so many denials. Now, do we have a role in that? Yes, ma'am. Yes, sir, we do. But what are some of the other departments or is there another department that contributes to not denials? Patient access and registration, HIM, health information management, billing or finance, all of the above or none of the above. So who else would contribute to denials? I'll give you just a couple of seconds here since there will be still put in. Your responses, this 1 is tricky bad because you're not just talking about clinical denials. You're also talking about administrative Tony. That is a good point. Um, and that answer it really now. Every department of the is listed can contribute. We could even say that nursing could contribute. Let's say, if you have a per diem case rate, and the patient was NPO for a procedure, and they got fed. So they had to stay an extra day. That could be their issue. I mean, physicians, a lot of it, but it really is any of those could be responsible billing and finance can be responsible for as Tony talked about technical or administrative denials, maybe not timely billing, maybe not being able to timely appeal their part of a denial. So, it is a lot of people that are involved in that with us. And I think we have to, we have to stand up for ourselves because we're here to coordinate and we need to coordinate. And that's why, you know, we're working with the hospital right now that I don't know that we've ever, we have ever really heard this for the CFO has an expectation of greater coverage on the weekends. We, we had, you know, kind of have that desire, but it's a clear direction. So important. Oh, whoops. I forgot to do my little trick. Okay. There you go, Tony. Oh, my God. It's just the last slide. Really? Okay, please. And of course, it's a long one. So you receive a communication from a commercial insurance payer saying the patients in patients hospital stay has been denied due to lack of medical necessity. Your 1st step is what? So the patient. You've looked at the record, maybe you felt that medical necessity was met. Should you let the the patient know that their hospital stay is denied and they will be responsible for the to pay the bill contact the attending physician to let him or her know, call the CFO to let him or her know that the hospital isn't going to get paid contact the physician advisor to let him or her know about the denial determine if the hospital is going to pay the bill. good good good excellent Okay. So, Lindsay, do we have just general questions at all? I'm scrolling through the chat here to make sure I haven't missed anything. I don't see any just general questions for the material. So, if anybody has any, you can go ahead and we type in those in here. Let's see. Oh, this. How about this last one? Yep. Do you see you are going to AI? Okay. Well, with Cortex or Excellus, that is an AI platform, as I understand it. I think it may, I don't think it will ever replace a UR nurse, but it might allow you, I mean, one of the things Tony and I were talking about with the client yesterday, and I might have mentioned it even earlier, is can we use AI in the ED because it's hard to figure out medical necessity. Things are happening really quickly. Doctors want to move the patients out of the ER. So, the question is, how quickly does your AI respond? And at this hospital, they have both, I think they have Milliman and InterQuala and Cortex, I can't remember, but the one thing, they have one of the other medical necessity programs, but Cortex or Excellus does not respond quickly enough, and we need to understand that better for it to help be the identifying factor. The one thing that Cortex is talking about is they do have different payers that are agreeing that if a patient has 26 points or it's a point category, that is how they determine medical necessity. So, they have a few payers that have agreed that denials or, excuse me, inpatient criteria will be met if you reach X number of points. So, I think it'll come. I just think there's so much about AI right now, and we need to see a little bit more. I don't believe it will ever replace you taking a look and validating, and then also talking with the physician about it. Tony, I don't know, what do you think about AI? Yeah, no, I kind of agree with what you're saying. I mean, we can't imagine the future in terms of technology, so it's hard to say, and I think it's a good tool for when it's a simple case and it's obvious that the patient meets criteria, you know, it's those more complex cases where you kind of have to really dig in and connect the dots and all of that. you know, it might be less helpful. So that's how I see it at this juncture, but, you know, things are changing so quickly. It's really kind of hard to know, but we should know more. Who knows what they did while we were on this webinar, you know? Exactly. It could be done. Perfect. I don't see any other pending questions at this time. You all do see both Bev and Dr. Sess's contact information here on the screen. And I know that some of you have already been in contact with them with your questions. And please continue to reach out. I know that they would be happy to help in any way that they can. And I am just so thankful that you both shared your time and all this wonderful information with all of our attendees here. I think that it has just been very well received and very helpful. I've just enjoyed working with you. And I thank all of our attendees for all of your engagement throughout this series. It's been wonderful. I know a few have had questions, and that means that others who are on the webinar have also had that similar question. So I thank you again for asking those questions and for being so engaged throughout the series. It's been wonderful. I did go ahead and post just some final comments there for you all in the chat. Just as a reminder, just as in every session in this series, you will receive an email tomorrow morning, and it will come from that educationnoreplyatzoom.us email address. So if you don't see it in your inbox in the morning, it could very well be in one of your additional folders, spam, quarantine, or junk, because it's coming from that Zoom email. So check those additional folders there. And if you still don't see it and you'd like to go back and access the recording of today's session, you can use that same Zoom link that you're using to join us for the live presentation to also access the recording. And then just remember that the recording is available for 60 days. And again, that applies to each of the sessions in our series. So each of the recordings are available for 60 days from the date of that original live session. You will just need to click on that Zoom link, type in your information. That will prompt an email to come to us for approval. And then we approve those very quickly, typically within a few moments of receiving the request. But we ask that you give us one business day to grant those approvals. And then you'll receive a confirmation email from Zoom allowing you access into that recording. And again, if we can be of further assistance, or if you do have any questions, you can always reach out to us at education at gha.org. We'll be happy to pass along your questions to our speakers.

order before surgery

observation service

patient admission

CMS regulation

short-term stay

two midnight stays

outpatient surgeries

IV antibiotic

physician advisors

shoutouts

Thanksgiving

weekend

discharge

inpatient

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