Thursday, February 10, 2005
Medicrazy Part III
Since it's a slow news day, I think it's time to post some more about my favorite bureaucratic institution, Medicare (My earlier Medicare posts are here and here).
When a patient, with Medicare as their principle payer, is admitted to the hospital they are either placed in 23 hour observation or inpatient status depending on the reason for the admission.
23 hour observation is (supposed to be) used to determine if a patient requires inpatient admission. This determination is to be made within 24 hours (hence the name). For example, a person with a history of asthma presents with wheezing and some shortness of breath with activity. At that point they don't meet inpatient criteria (clinical/laboratory/radiological findings considered significant enough by the government to warrant IP admission). The patient can be placed in observation, given some respiratory treatments, respiratory testing, and monitoring for any potential progression of the disease/symptoms that would warrant more intensive treatment and inpatient admission.
Now that's the way it's supposed to work, but like many things regarding Medicare, that's not how it's followed. Medicare pays a smaller amount to the hospital for 23 hour observation care than inpatient care because the care is usually less intense. But this fact is being used to cut costs.
As I stated earlier, the government sets what criteria must be met in order to admit a person to inpatient status. Since inpatient status is generally more expensive for Medicare, it's becoming harder to meet admission criteria. For example, in many states (because the criteria vary some depending on the state) for a person with vomiting, diarrhea and subsequent dehydration to be admitted IP they have to be NPO (meaning not allowed to have any fluids/food by mouth). This makes no sense, but it works wonders for Medicare because they can then deny the entire inpatient stay if this order isn't followed.
Another tactic used by Medicare is to perform a retro review after the patient was discharged and force the hospital to bill the admission as 23 hour instead of the original inpatient bill. For example, a person is admitted inpatient with chest pain in order to rule out a myocardial infarction. Chest pain with a cardiac care unit placement meet inpatient criteria. The Medicare Gestapo ( physician review organization or their new name of quality improvement organization) will review the chart after discharge. If the patient turned out to have no acute cardiac event the PRO will, many times, deny the stay on the grounds that the patient never needed admission.
Of course the physician has no way of knowing that the chest pain was not cardiac in nature at admission and the grounds for the denial directly oppose Medicare's own rules of not using evidence after admission to deny an inpatient stay. However, the PRO knows that most physicians don't have the time, and most hospital don't have the guts, to fight back.
Hospitals know that if they push back too hard they could be in for a full-out audit of all their records. And since the government sets the rules, and the interpretation of those rules, the hospitals are at a significant disadvantage. Hospitals (especially small rural ones) only have a limited amount of money for legal defense whereas the government has an unending supply of funds in which they can carry on an unending legal assault.
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When a patient, with Medicare as their principle payer, is admitted to the hospital they are either placed in 23 hour observation or inpatient status depending on the reason for the admission.
23 hour observation is (supposed to be) used to determine if a patient requires inpatient admission. This determination is to be made within 24 hours (hence the name). For example, a person with a history of asthma presents with wheezing and some shortness of breath with activity. At that point they don't meet inpatient criteria (clinical/laboratory/radiological findings considered significant enough by the government to warrant IP admission). The patient can be placed in observation, given some respiratory treatments, respiratory testing, and monitoring for any potential progression of the disease/symptoms that would warrant more intensive treatment and inpatient admission.
Now that's the way it's supposed to work, but like many things regarding Medicare, that's not how it's followed. Medicare pays a smaller amount to the hospital for 23 hour observation care than inpatient care because the care is usually less intense. But this fact is being used to cut costs.
As I stated earlier, the government sets what criteria must be met in order to admit a person to inpatient status. Since inpatient status is generally more expensive for Medicare, it's becoming harder to meet admission criteria. For example, in many states (because the criteria vary some depending on the state) for a person with vomiting, diarrhea and subsequent dehydration to be admitted IP they have to be NPO (meaning not allowed to have any fluids/food by mouth). This makes no sense, but it works wonders for Medicare because they can then deny the entire inpatient stay if this order isn't followed.
Another tactic used by Medicare is to perform a retro review after the patient was discharged and force the hospital to bill the admission as 23 hour instead of the original inpatient bill. For example, a person is admitted inpatient with chest pain in order to rule out a myocardial infarction. Chest pain with a cardiac care unit placement meet inpatient criteria. The Medicare Gestapo ( physician review organization or their new name of quality improvement organization) will review the chart after discharge. If the patient turned out to have no acute cardiac event the PRO will, many times, deny the stay on the grounds that the patient never needed admission.
Of course the physician has no way of knowing that the chest pain was not cardiac in nature at admission and the grounds for the denial directly oppose Medicare's own rules of not using evidence after admission to deny an inpatient stay. However, the PRO knows that most physicians don't have the time, and most hospital don't have the guts, to fight back.
Hospitals know that if they push back too hard they could be in for a full-out audit of all their records. And since the government sets the rules, and the interpretation of those rules, the hospitals are at a significant disadvantage. Hospitals (especially small rural ones) only have a limited amount of money for legal defense whereas the government has an unending supply of funds in which they can carry on an unending legal assault.
# posted by Joe Florida @ 1:05 PM 
