Probe and Educate Audit Activity Update

Probe and Educate Audits by the Medicare Administrative Contractors (MACs) for compliance with the 2014 Inpatient Prospective Payment System (IPPS) Final Rule 1599 are underway, and are currently scheduled to continue through March, 2015. As we examine the MAC Probe and Educate audit activity throughout the country it is evident many of the issues that have appeared in the Recovery Auditor (RAC) reviews of short stays are also present in MAC reviews as described below:

Inability to solve issues which should be easily addressed.
For example, clients have had denials issued where the patient stayed in the hospital as an inpatient (after the inpatient order) greater than two midnights and the case was denied as not meeting the two midnight benchmark. This case should not be reviewed as part of the Probe and Educate process. Similarly, there are denials where the MAC indicates there was no signed inpatient order or the medical record information was missing, whereas the information is clearly in the record and was sent. One client reported that the client never received an ADR request. The case was denied because the record was not sent and the MAC refused to re-send the ADR request and to allow the client to respond. The client was advised to follow the appeal process. A process for a rapid resolution of denials based on technical/administrative issues would reduce the burden on hospitals, auditors and the already overwhelmed Office of Medicare Hearing and Appeals.

Inappropriate focus on actual time in the hospital.
It is clear in the regulations that the inpatient decision is to be based on the physician’s reasonable expectation that the patient requires services in the hospital for a period spanning two midnights, not whether the patient actually stayed in the hospital for a period spanning two midnights. MACs are denying cases where the clinical documentation clearly supports the physician’s determination that the patient required care in the hospital for a period spanning two midnights, but because the patient did not actually stay two midnights, reimbursement is denied. This has happened in cases where the patient died (which CMS explicitly addresses), in cases where the patient refuses additional inpatient treatment, and in cases where the patient unexpectedly improves. Sometimes the language from the reviewer provides that the physician failed to note that the patient improved more rapidly than expected; No requirement exists for the physician to retrospectively examine the order at the end of the stay if the inpatient order is appropriately supported when issued, nor should reimbursement be denied because of events subsequent to an appropriate order. Again, these cases should be resolved promptly in favor of the hospital without the hospital being forced to engage in a lengthy and costly appeal process.

Lack of guidance on medical necessity analysis.
The denial may indicate that the clinical documentation does not support the expectation that the patient requires care for a period spanning two midnights even though there is an explicit statement that the patient is expected to require care spanning two midnights, the plan of care clearly delineates the services needed and the history, physical exam and notes demonstrate the need for services. Some MACs have refused case by case discussion and analysis and have advised the hospitals to appeal.

Lack of peer to peer process for resolution.
Because denials based on whether the admitting practitioner’s judgment that the patient is expected to require services in the hospital for two midnights is a reasonable judgment based on the clinical documentation in the record, it is, at its core, a review of the admitting physician’s clinical judgment as reflected in and supported by the clinical documentation. Review processes which do not require a physician reviewer to examine the clinical processes, and do not establish a mechanism for peer to peer resolution are inherently flawed. When opportunities for discussion do exist it is rare for the discussion to be based on evidence-based literature or a true discussion of the appropriate standard of care. There should be an independent physician review of clinical analysis which is grounded in sound clinical judgment supported by medical literature, not merely an auditor’s judgment that the patient just “wasn’t sick enough” to need inpatient level of care.

Difficulty with understanding the review standards.
Hospitals and other providers want to understand the rules and the standards by which they will be judged. Whether a stay is medically necessary is fact-dependent, and hospitals are expected to be able to discern whether a stay will be judged as medically necessary by auditors. How does utilization management make the determination? If a case meets an evidence based criteria for an inpatient stay is the case “safe” from review? No, because an inpatient stay is only appropriate if there is a documented expectation that the patient requires services in the hospital for a period spanning two midnights. An ICU stay which meets “inpatient” criteria in Interqual® or Milliman Care Guidelines (MCG) does not meet Medicare inpatient guidelines IF the patient is not expected to require services in the hospital for a period spanning two midnights. Conversely, even if the services are not of such intensity that the criteria would support an inpatient status, if clinical documentation supports the physician’s expectation that the patient clinically requires services in the hospital for a period spanning two midnights then the case is appropriately inpatient.   The quality of the clinical documentation supporting the expectation of two midnights is critical. A challenge for hospitals is to ensure that BOTH the technical certification requirements are met and that the clinical documentation standards are met. Clinical documentation should be clear as to the plan of care spanning two midnights, and why the plan of care is needed. Clinical documentation is more important than ever because there is an express regulatory requirement that the expectation of two midnight’s be supported by the medical “evidence” in the record. Great clinical documentation is imperative and both nurse reviews and physician advisor reviews can help ensure that the record contains adequate and appropriate documentation.

If you have any questions please do not hesitate to contact us.

Joan C. Ragsdale
Chief Executive Officer
(205) 970-8804

Ann McEwen Purdy
Chief Development Officer
(205) 314-8859