Providers ask CMS to over­haul short-term stay pol­icy

Modern Healthcare - - FRONT PAGE - Paul Barr

Acute-care hospi­tal and nurs­ing home in­dus­try rep­re­sen­ta­tives are ask­ing the CMS to over­haul the way the Medi­care pro­gram clas­si­fies and re­im­burses for pa­tients who are treated in a hospi­tal for a short time.

Hos­pi­tals are get­ting short-changed by Medi­care in their treat­ment of short-term pa­tients, the Amer­i­can Hospi­tal As­so­ci­a­tion ar­gued in a com­ment let­ter that re­sponded to a call for pub­lic com­ment con­tained in the CMS’ Medi­care out­pa­tient prospec­tive pay­ment sys­tem rule re­leased in July.

Skilled-nurs­ing fa­cil­i­ties, mean­while, say nurs­ing home pa­tients in need of SNF care aren’t get­ting ap­pro­pri­ate care as a re­sult of the tech­ni­cal clas­si­fi­ca­tion troubles tak­ing place inside hos­pi­tals.

The provider groups ar­gue that the prob­lems are a re­sult of un­clear and evolv­ing CMS ex­pec­ta­tions for de­ter­min­ing whether a pa­tient is clas­si­fied as an in­pa­tient or an out­pa­tient on ob­ser­va­tion sta­tus, with the de­ci­sion car­ry­ing po­ten­tially big im­pli­ca­tions for hos­pi­tals, SNFs and pa­tients. The CMS de­clined to com­ment as a mat­ter of pol­icy re­gard­ing pend­ing rule­mak­ing.

“Be­cause of this weird pay­ment struc­ture, ev­ery­one’s in an awk­ward po­si­tion,” said Marsha Green­field, vice pres­i­dent of leg­isla­tive af­fairs for Lead­ing Age, an as­so­ci­a­tion for not-for-profit nurs­ing homes that sub­mit­ted a com­ment let­ter.

For hos­pi­tals, the AHA ar­gues in its com­ment let­ter, in­creas­ing aggressiveness in chal­leng­ing short-stay in­pa­tient Medi­care claims by des­ig­nated re­cov­ery au­dit con­trac­tors and Medi­care au­dit con­trac­tors is caus­ing fewer pa­tients to be clas­si­fied as in­pa­tients though that may be the more ap­pro­pri­ate des­ig­na­tion. Whether a pa­tient is con­sid­ered to be an ad­mit­ted in­pa­tient or on ob­ser­va­tion sta­tus—a clas­si­fi­ca­tion that can ap­ply to pa­tients in the hospi­tal for days—has di­rect pay­ment im­pli­ca­tions for hos­pi­tals, since that will de­ter­mine whether they are paid through Medi­care Part A or Part B. Physi­cians make that de­ci­sion, but sec­ondguess­ing from au­di­tors has cre­ated am­bi­gu­ity about who de­cides what con­sti­tutes an ap­pro­pri­ate ad­mis­sion, the AHA let­ter said.

Mean­while, the time spent un­der ob­ser­va­tion in a hospi­tal does not count to­ward a three­day min­i­mum re­quire­ment for that pa­tient to qual­ify for Medi­care-cov­ered SNF care. Green­field said Lead­ing Age of­fi­cials have no in­ter­est in how hos­pi­tals are paid for such pa­tients, but they do want a pa­tient’s time in the hospi­tal to count to­ward the three-day min­i­mum, al­low­ing for SNFs to pro­vide care. The nurs­ing home group Amer­i­can Health Care As­so­ci­a­tion makes a sim­i­lar re­quest in its com­ment let­ter.

Pa­tients are get­ting hurt fi­nan­cially by the con­fu­sion, as they gen­er­ally pay higher outof-pocket costs for the out­pa­tient-care clas­si­fi­ca­tion that goes with be­ing on ob­ser­va­tion, and may miss out on needed SNF care if tabbed as an out­pa­tient, the provider groups ar­gue. Medi­care pa­tients of­ten don’t un­der­stand the dif­fer­ence. “They find out they weren’t in the hospi­tal even though they were in the hospi­tal,” Green­field said.

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