Knowledge Base Article

For those of you that do not live in the state of Alabama it is hard to comprehend just how big college football is in this state. When I was new to the state one of the first questions people would ask is “which team are you for?” As a transplant from “up north,” (Tennessee), the obvious answer for me was neither.

In the world of Medicare and Acute Care Hospitals one main question that keeps being asked is, “are you an inpatient or an outpatient.” And for the Medicare beneficiary that has spent zero or one midnight in a hospital bed, though the answer will ultimately be inpatient or outpatient, it is not always an obvious answer.

The Comprehensive Error Rate Testing (CERT) Program is used to calculate the improper payment estimate for the Medicare Fee-for-Service Program. Each November, the Department of Health and Human Services (HHS) publishes the improper payment rate in the Agency Financial Report at www.hhs.gov/afr. CMS later publishes more detailed information in an annual Medicare Fee-for-Service (FFS) Improper Payments Report and Appendices. This article will focus on why patient status for zero and one day lengths of stay remains a focus, who is keeping a close eye on this dilemma and resources for you to help assess this patient population in your hospital.

Why Zero and One Day Inpatient Lengths of Stay Continues to be a Focus?

“Are you and Inpatient or Outpatient” still being a question for zero and 1 midnight hospitalizations is best demonstrated in the Appendices table Projected Improper Payments by Length of Stay. This table was new to the Appendices in 2014 and again appears in the 2015 report. Depicted below is a compare of data from the 2014 table and 2015 table. While the improper payment rate dropped 9.3% it is this group of claims that continue to have the highest error ate.

Table 1: “Projected Improper Payments by Length of Stay” 2014 to 2015 Compare

‍Who is Monitoring for Compliance with Patient Status Assignment?

Beneficiary and Family Centered Care (BFCC) QIOs and Recovery Auditors

HHS indicated in the FY 2015 Agency Financial Report that they are committed to reducing improper payments in the Medicare FFS program. One of the five corrective actions they believe will have a considerable effect in preventing and reducing improper payments is the update to the “Two Midnight” rule in the CY 2016 OPPS Final Rule. At the same time they announced the following two changes in their education and enforcement strategies.

• “Beginning on October 1, 2015, the Quality Improvement Organizations (QIOs) assumed responsibility to conduct initial patient status review of providers to determine the appropriateness of Part A payment for short stay inpatient hospital claims. From October 1, 2015 through December 31, 2015, short stay inpatient hospital reviews conducted by the QIOs will be based on Medicare’s current payment policies.
• Beginning on January 1, 2016, QIOs and Recovery Audit Contractors (RACs) will conduct patient status reviews in accordance with policy changes finalized in the Hospital Outpatient Prospective Payment System rule (CMS-1613-P) and effective in calendar year 2016. Effective January 1, 2016, RACs may conduct patient status reviews only for those providers that have been referred by the QIO as exhibiting persistent noncompliance with Medicare payment policies.”

To learn more about the transition of patient status reviews, you can:

• Read a related article at http://www.mmplusinc.com/news-articles/item/two-midnight-rule-once-again-to-be-or-not-to-be;or
• Join us for our 2016 Medicare Updates Webinar tomorrow afternoon.

Office of Inspector General

• FY 2014 and 2015 Work Plans: Inpatient Admission Criteria (OEI; 00-00-00000)

With the implementation of the “Two Midnight” Rule, the OIG added new inpatient admission criteria to the Work Plan in FY 2014 and 2015. This issue was focused on determining the impact of the new admission criteria on hospital billing, Medicare payments, and beneficiary payments. It also was focused on determining how billing varied among hospitals in FY 2014. This focus was based on the fact that “previous OIG work identified millions of dollars in overpayments to hospitals for short inpatient stays that should have been billed as outpatient stays. Beginning in FY 2014, new criteria state that physicians should admit for inpatient care those beneficiaries who are expected to need at least 2 nights of hospital care (known as the “two midnight policy””). Beneficiaries whose care is expected to last fewer than 2 nights should be treated as outpatients. The criteria represent a substantial change in the way hospitals bill for inpatient and outpatient stays.”

• FY 2016 Work Plan: Hospitals’ use of outpatient and inpatient stays under Medicare’s two-midnight rule (OEI; 02-15-00020)

With hospitals now entering into their third fiscal year under the “Two Midnight” Policy, as part of the FY 2016 Work Plan the OIG will “determine how hospitals’ use of outpatient and inpatient stays changed under Medicare’s two-midnight rule, as well as how Medicare and beneficiary payments for these stays changed, by comparing claims for hospital stays in the year prior to the effective date of the two-midnight rule to stays in the year following the effective date of that rule. We will also determine the extent to which the use of outpatient and inpatient stays varied among hospitals. CMS implemented the two-midnight rule on October 1, 2013. This rule represents a substantial change to the criteria that hospital physicians are expected to use when deciding whether to admit beneficiaries as inpatients or treat them as outpatients.”

Hospital Zero and One Day Inpatient Stay Volume

The CERT, OIG, BFCC-QIOs and potentially the Recovery Auditors are monitoring hospital’s compliance with the “Two-Midnight” policy by auditing zero and one midnight inpatient claims. But, do you know how this specific patient volume has changed where you work?

PEPPER Report

One source available to IPPS Participating Hospitals is the Program for Evaluating Payment Patterns Electronic Report (PEPPER). In the PEPPER User’s Guide, the OIG encourages hospitals to develop and implement a compliance program and conduct regular audits as a part of this program to ensure charges for Medicare services have been correctly documented and billed. They note that the PEPPER “can help guide the hospital’s auditing and monitoring activities.”

This report focuses on Medicare severity diagnosis related groups (DRGs) and discharges at risk for improper payment due to billing, coding and/or admission necessity.” One-day and Same-day Stays for Medical and Surgical DRGs are target areas in the report. A hospital is compared to its state, Medicare Administrative Contractor (MAC) Jurisdiction and the Nation for each target area.

The tables below compare the Nationals, J-J MAC Jurisdiction (Alabama, Georgia and Tennessee) and Alabama’s 80th Percentile for the 3rd quarter (April – June) of the Fiscal Year prior to implementation of the “Two-Midnight” Policy (2013), one year after implementation (2014) and the most current 3rd quarter fiscal year data (2015).

The PEPPER provides the following suggested interventions for Hospitals that are High Outliers:

“This could indicate that there are unnecessary admissions related to inappropriate use of admission screening criteria or outpatient observation. A sample of same- and/or one-day stay cases should be reviewed to determine if inpatient admission was necessary or if care could have been provided more efficiently on an outpatient basis (e.g., outpatient observation). Hospitals may generate data profiles to identify same- and/or one-day stays sorted by DRG, physician or admission source to assist in identification of any patterns related to same- and/or one-day stays. Hospitals may also wish to identify whether patients admitted for same- and/or one- day stays were treated in outpatient, outpatient observation or the emergency department for one or more nights prior to the inpatient admission. Hospitals should not review same- and/or one- day stays that are associated with procedures designated by CMS as “inpatient only.”

RealTime Medicare Data

Another source that can assist you is our sister company RealTime Medicare Data (RTMD). RTMD collects over 680 million Medicare claims annually from 23 states and the District of Columbia, and allows for searching of over 5.1 billion historical claims. In response to the “Two-Midnight” Policy, RTMD has available in their suite of Inpatient Hospital reports a One Day Stay Report. This report enables a hospital to view one day stay paid claims data by DRG and Physician to direct where audits should be focused. For further information on all that RTMD has to offer you can visit their website at www.rtmd.org.

Resources

Department of Health and Human Services Fiscal Year 2015 Agency Financial Report: http://www.hhs.gov/afr/fy-2015-hhs-agency-financial-report.pdf

The Supplementary Appendices for the Medicare Fee-for-Services 2015 Improper Payments Report: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/CERT-Reports-Items/Downloads/AppendicesMedicareFee-for-Service2015ImproperPaymentsReport.pdf

FY 2016 OIG Work Plan: http://oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf

Short-term Acute Care Program for Evaluating Payment Patterns Electronic Report User’s Guide 18th Edition: https://www.pepperresources.org/Portals/0/Documents/PEPPER/ST/STPEPPERUsersGuide_Edition18.pdf