Preparing for Probe and Educate Audits

On Friday, November 1, 2013, CMS described its approach to probe audits which will be conducted through March 31, 2014. It is important to be prepared to avoid “repeat” or broader future audits by the MAC.  The Recovery Auditors (RACs) will be authorized to review short stays in 2014, so compliant processes are important to prevent future recoupments as well.

How do you avoid audit, and future recoupments? As changes in process are implemented, it is important to establish review processes that ensure that appropriate orders are entered timely. Those processes may be different for admissions originating in the Emergency Department, and direct admits because staffing varies.  It is important to ensure that processes are in place on a 24/7 basis.   There are three major areas of focus:

1AVOID THE AUDIT ENTIRELY.  In those cases where the physician expects the patient to require care spanning two midnights on the front end, and the appropriate inpatient order is entered timely (before the first midnight) the case will not be subject to the MAC probe.      

Identify cases appropriately exempt from the probe audits and get the appropriate order in timely. Cases exempt from the probe audits (and which the RACs are not supposed to audit absent evidence of bad conduct like gaming or intentional delays) are those cases where the patient stays two midnights after the formal inpatient order.   Review patient status when the decision is made to place the patient in a bed before midnight. We recommend “self-audits” as new processes are implemented.  If you can “self-audit” concurrent with the care and prior to discharge, it is possible to correct deficiencies on the front end.

Concurrent review process:  check every case as soon as the decision is made to place the patient in a bed for the following:

  • Is there an order for status?
  • Has the physician determined the order based on the answer to the question of whether the patient is expected to require care in the hospital for a period spanning two midnights.
  • All  cases are reviewed by staff with initial screening criteria to examine whether clinical documentation supports required hospital care.
  • If there is an inpatient order and the case doesn’t meet screening criteria,  and the case manager does not otherwise find that documentation clearly supports the medical necessity of care in the hospital, refer for secondary review by a physician advisor.
  • If there is an outpatient order, but on screening the case manager determines that the patient requires care in the hospital spanning two midnights, refer for secondary review by a physician advisor.
  • If there is an outpatient order and the case manager determines  outpatient status is appropriate, make certain the patient is followed the next day and either discharged prior to the second midnight or admitted if the medical necessity supports the patient remaining in the hospital to receive needed services.
  • Once order and inpatient status are finalized ensure that  order and certification elements are in place and signed by physician with admitting privileges prior to discharge.

Retrospective process check:

  • Was every case reviewed prior to, or simultaneously with bed placement to assess the items above?  If it did not happen, why? What changes need to be made?

Review a sample of cases where the patient stayed two midnights, but the order was not entered until after the first midnight to determine whether there was a “default” to outpatient with observation services or a failure to recognize that the patient required care for a period spanning two midnights (inappropriate), whether short term tests were needed to determine the plan of care or o a short term plan of care was anticipated, but the stay was longer than anticipated (was appropriate for outpatient with observation services initially), or whether process issues prevented a determination or prevented the facility from billing inpatient services appropriately before the first midnight (needs to be addressed).

  • For inpatient cases, does the clinical documentation support inpatient status? (Remember that there is an opportunity to rebill based on self-audit but only within timely filing limits).
  • Is there a feedback loop to ensure 100% compliance and to continually modify and improve processes?
  • Is there follow up on 100% of the outpatient observation services cases?
  • Is there follow up to verify certification on 100% of the inpatient cases?
  • Inter-rater/education analysis needs to be conducted to ensure that decision-making is sound.

2FOCUS ON ONE MIDNIGHT POST ORDER STAYS. Review and address cases where the patient spends the first midnight in an outpatient setting and upon review prior to the second midnight, a determination is made that the patient should be admitted as an inpatient.

Every patient should be reviewed prior to the second midnight.  One goal of the new regulations is to prevent lengthy outpatient stays.  Case managers should have processes in place to review each patient stay before the “second midnight.”

Concurrent review should include:

If there is an inpatient order prior to the first midnight, does the plan of care and treatment support the initial order? If there is an outpatient with observation services order, is the patient expected to require care in the hospital a second midnight ,and if so is there an appropriate inpatient order, and:

  • Does the patient order reflect the physician’s medical judgment that the patient is expected to require care in the hospital a second midnight?
  • Based on initial screening criteria, is the physician’s judgment that the patient requires care in the hospital supported by clinical documentation?
  • If the documentation does not support the inpatient order, is there secondary physician advisor review?
  • If there is an order for “extended observation” services, refer for secondary physician advisor review since “extended observation—beyond two midnights” should not be medically required (because if the patient REQUIRES care in the hospital beyond two midnights, the patient should be an inpatient).
  • Was the first night determination of outpatient status correct, or is the case one which can be used as a process improvement tool?

Retrospective review should include:

  • Was every case where the patient stayed less than two midnights after the inpatient order reviewed by case managers at the time the inpatient order was entered (in addition to the review at the time of bed placement)?
  • Was an initial screen done on each case at the time of the inpatient order and when was the screen performed?
  • Was a secondary physician advisor review done if the case did not meet initial screening criteria?
  • Did the clinical documentation support the billing status?  (Remember that self-audits and rebilling must occur within a year from date of service).
  • Is there a feedback loop to initial intake review processes to ensure that process issues are addressed?
  • Is there inter-rater reliability testing and education to ensure that determinations are accurate?
  • Are processes in place to ensure admission orders and certifications are checked prior to patient discharge?

3) CAREFULLY REVIEW OUTPATIENT WITH OBSERVATION SERVICES CASES.  OUTPATIENT WITH OBSERVATION SERVICES CASES GREATER THAN 24 HOURS SHOULD BE REVIEWED INTERNALLY TO ENSURE THAT CORRECT DETERMINATIONS ARE MADE WITH RESPECT TO STATUS.  Because the changes focus on addressing issues with “inpatient” certifications, and “inpatient processes” those patients who present in the ED after midnight and are placed in a bed may not be evaluated until they are approaching their third day in the hospital unless careful attention is paid to those patients.  In addition, the law was designed to eliminate lengthy observation stays so it is appropriate to identify barriers to eliminating lengthy outpatient stays.

As always, we are available to assist with physician advisor reviews, initial screening, internal audit activities, and of course, as you defend audits If there are questions, please do not hesitate to contact Joan Ragsdale at jragsdale@medmanagementllc.com , Dr. Greg Palega at gpalega@medmanagementllc.com or Ann Purdy  at apurdy@medmanagementllc.com.

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