Physician Reviewer Training: Utilization Appeals and HW-DRG Reviews

1. Physician Reviewer Training:Utilization Appeals and HW-DRG Reviews Sharon Hoffarth, MD, MPH, FACPM Chief Medical Director

2. Objectives • Understand the distinctions between observation and inpatient admissions • Understand the beneficiary discharge appeals process • Understand the basics of higher-weighted DRG (HW-DRG) validation reviews

3. Hospital Admissions:Inpatient vs. Observation Status

4. The Fundamental Hospital Admission Decision: Inpatient vs. Observation • Treatment longer than 24 hours expected • Outpatient treatment has not been effective • Inpatient-only procedure necessary • Continuous monitoring necessary • Points of Entry for Outpatient Observation

5. Inpatient Admission Considerations • Severity of presenting signs and symptoms • Predictability of the clinical course • Existence of co-morbid conditions which may negatively impact course • Potential for complications • Services required upon presentation • Diagnostic procedures available

6. Inpatient Admission Documentation • The physician’s admission order should: -- specify inpatient vs. observation status -- have the date and time • Clinical documentation (e.g., in initial note or H&P) is present to support medical necessity for inpatient admission • No “back-dating” is allowed

7. What are Observation Services? • Services furnished by a hospital including: • use of bed • periodic monitoring by staff • requires physician order • Reasonable and necessary • evaluate outpatient condition • determine inpatient admission need

8. Why Observation Services? • Determines need for inpatient admission • Rapid response to treatment is expected • Patient has unusually prolonged recovery period following an OP procedure

9. ObservationDocumentation • Observation admission order with date and time • Assessment of patient risk to determine benefit from observation care • Timed and signed admission notes, progress notes and discharge notes

10. Observation Services Not Reasonable When… • Services not reasonable or necessary for diagnosis or treatment of patient • Services provided for convenience of patient, family or physician • Services covered under Part A • Services that are part of another Part B service • Standing orders for observation after OP surgery • Custodial care

11. Observation or Inpatient? Hospitalization required? Yes 24 hours adequate to evaluate, treat or respond? No No Inpatient Yes No acute hospital care Observation

12. Circumvention of PPS (Prospective Payment System) • Premature discharge (PD) • Subsequent re-admit to same hospital • Re-admit • Care not provided during 1st stay • Inappropriate transfer • PPS to PPS-exempt • PPS-exempt to PPS

13. Procedure review • Reasonable? • Medically necessary? • If unnecessary, then quality concern? • Quality appropriate?

14. Appeals Review • Two types • Retrospective • Concurrent • Protection for beneficiary • Determine whether care is covered or not

15. Retrospective Appeals Review • Document medical basis for agreement or disagreement • Hospital should NOT issue if…… • Patient requires initial or continued care • Patient requires SNF and no SNF bed available

16. Concurrent Appeals Review • Settings for concurrent discharge appeals include: hospital, skilled care, home health, hospice, outpatient rehab • 7 days/wk + holidays • Hospital overnights or faxes record • NPR contacts patient/family and hospital • Immediate PR review (phone) • Contact Attending Physician • Voluntary PR schedule for interested PRs to cover weekends and holidays

17. Concurrent Appeals Review Continued • Physician review decision • Non-Physician Reviewer at Primaris follows up with hospital, attending physician and patient • Immediate notification of decision by telephone • Additional notification is also sent in writing

18. Reconsideration Reviews • Second level of review (reconsideration) can be requested by the beneficiary when the QIO has upheld the discharge by the provider • PR must not have been involved previously • PR must be board certified or board eligible

19. Important Message from Medicare (IMM) • Important Message from Medicare (IMM) • Explains pt’s rights under Medicare • Expedited QIO review when hospital or MA plan determines acute care no longer necessary • Given to pt TWICE during stay • Upon admission (or w/in 48h of admit) • No fewer than 48h prior to D/C • Instructs how patient can contact QIO if disagrees with discharge

20. Discharge Appeal -- Hospital and Concurrent: QIO Internal Process • Accepts requests for review 24/7 • Provider must supply the medical record documentation as requested by the QIO • QIO Non-Physician Reviewer who is working the case solicits additional input from • The Patient or her representative • Provider • Medicare Advantage plan as applicable • Attending physician (depending on the Physician Reviewer’s preference)

21. Discharge Appeal -- Hospital and Concurrent: QIO Internal Process (continued) • QIO must: • Verify appropriateness and comprehensiveness of Discharge Planning • Complete review within 24 hours • Notify beneficiary or representative immediately upon completion of review

22. All Discharge Appeals Reviews –Physician Reviewer Responsibilities • Based upon medical necessity of continued acute care • At the time of facility intent to discharge and issuance of the notice of non-coverage, did patient still require acute care services? • If NOT, then agree with the discharge • If acute care is still required, disagree with the discharge • Most importantly, the PR’s review must document the medical basis for agreement or disagreement with the discharge with a detailed rationale to support his decision

23. All Discharge Appeals Reviews –Physician Reviewer Responsibilities (continued) • The Physician Reviewer provides his decision to the Primaris NPR • Verbal or fax (your choice) • No e-mail • E-mail is not secure • NPR will send • Copy of decision for signature • Invoice voucher for reimbursement

24. Concurrent Discharge Appeals Decisions:-- Financial Liability for the Patient • QIO agrees with the provider’s decision to discharge the patient • Patient is financially liable if he chooses to stay • Patient can request a Reconsideration • QIO disagrees with the planned discharge • Patient is not financially liable and can stay in acute care • If QIO reverses the initial appeals decision (agreeing with the discharge) the patient is not financially liable for medical costs incurred during the reconsideration

25. Higher-Weighted Diagnosis Related Group Reviews (HW-DRG)

26. Principles of HW-DRG Review • Source of information: -- The provider’s claim for services provided to a beneficiary -- The Medical Record • Appropriate designation of the Principal Diagnosis • Addition/Deletion of Secondary Diagnoses • Confirmation of Procedures

27. HW-DRG Reviews – Medicare Definitions of Principal and Secondary Diagnoses • Principal Diagnosis: “The condition that, after study, is determined to have occasioned the admission of the patient to the hospital for care.” • Secondary Diagnosis/Additional conditions affecting patient care • Clinical evaluation • Diagnostic procedures • Increased nursing care/monitoring • Therapeutic Tx • Extended LOS

28. HW-DRG Reviews – Physician Reviewer’s Responsibilities • Examine all available medical record information • H&P • Physician notes • Hospital course • Evaluation (lab, X-rays, etc.) • Treatment • Consultations • Discharge summary • Evaluate the information from a Clinical Perspective • NOT expected to code

29. HW-DRG Reviews – Common Coding Guidelines • NPR will ask specific question • Guidelines assist in PR determination • Use applicable clinical judgment

30. For questions and additional information, call Rita Ketterlin at 1-800-735-6776, ext. 153