Admission
- Care Guidelines
Quality of Care
Coding
Discharge
Procedure
Quality Improvement Plans
- Who makes admission necessity denial decisions?
Only physicians can make adverse decision determinations. The physician reviewer is of the same specialty as the admitting physician for admission necessity determinations. - Can a nurse reviewer approve an admission?
A nurse reviewer may approve an admission when care required by the patient can only be provided in a hospital inpatient setting and the screening guidelines are met.
Cases failing to meet screening guidelines are referred to physician reviewers who are licensed and actively practicing in the same state where care was provided. - What kinds of admissions are denied?
Medicare doesn’t pay for care that is not medically necessary or care that is not provided in the appropriate setting. - What is the most frequent cause of admission denials?
The most frequent cause of admission denials is a lack of physician documentation concerning the patient’s current illness and failure of attempted outpatient treatment. Not all patients are appropriate for outpatient treatment attempts prior to admission. However, if outpatient treatment was attempted and failed, it should be documented in the record. - Will an admission to acute care be denied if the patient goes home the next day?
Physician reviewers base their admission necessity determinations on the information that was available to the admitting physician at the time the decision was made to admit the patient. When the patient was discharged has no impact on the admission decision. - What else causes admission denials?
Another frequent cause of admission denials is because the hospital is not using or is limiting outpatient observation level of care, or the physician is not familiar with outpatient observation. - How does the physician decide if the patient should be outpatient observation?
Patients are generally admitted to outpatient observation to evaluate for possible inpatient admission or for treating complications following outpatient surgery.
If the physician determines the patient will most likely need more than 24 hours and medical necessity is evident, the patient should be admitted to acute care. - Why can’t patients be kept longer than 24 hours in outpatient observation?
Medicare patient may be kept in outpatient observation 48 hours (or longer if documentation supports the necessity). Please contact your fiscal intermediary for conditions and requirements. - Can we send patients from outpatient surgery to outpatient observation?
Patients in outpatient surgery can’t be admitted to outpatient observation post-operatively, unless there are complications. - Why do the physicians still get paid when the hospitalization is denied?
The physicians are paid because Medicare assumes the patient would have sought physician care regardless of the setting. The patient may have required physician care even though they did not require an acute inpatient admission.
- What guidelines are used by the QIO?
IFMC has chosen to use the Milliman Care Guidelines. The guidelines will be used for nurse screening of Medicare acute care inpatient admissions, medical necessity of procedures and quality of care. In addition to admission necessity guidelines, the guidelines contain evidence-based knowledge and best practices with an annotated bibliography, references and footnotes. Critical pathways are also included. - Are Milliman care guidelines stricter about length of stay than other guidelines?
Screening guidelines are used by IFMC for medical necessity only. The QIO doesn’t routinely review length of stay for Medicare patients in acute care at PPS hospitals. - What guidelines do physician reviewers use?
Physician reviewers make determinations based on their medical judgment and information contained in the medical record. Admission decisions are based on information available to the admitting physician at the time the admission decision was made. - Why do IFMC nurses use guidelines?
IFMC nurses use guidelines as a screening tool to determine if a case should be referred to a physician reviewer for a medical necessity or quality of care. - What are hospitals required to use for screening guidelines?
Hospital personnel are not required to use the same guidelines as the QIO. Hospitals may use screening guidelines of their choice when performing review. We share information about QIO use of screening guidelines only to provide you information about how your Medicare records will be reviewed by the QIO. We understand a hospital’s financial concern when determining guideline choices.
- Who determines if quality of care concerns exist?
Potential quality of care concerns will be reviewed by a physician reviewer of the same specialty as the physician who provided the care in question.
- Who makes coding change decisions?
The IFMC coding specialists make changes if the coding doesn't’t conform to coding guidelines; otherwise, physician reviewers of the same specialty as the attending physician make coding determinations.
- Why does the case review department request quality improvement plans (QIPs)?
We are required to perform pattern analysis of actual case review outcomes to determine if there is a pattern of admission or coding errors or if a physician reviewer determines quality of care could be enhanced by a potential system change within the hospital.
Our goal is to help hospitals identify quality improvement opportunities. We believe it is our responsibility to assist hospitals with the goal of improving care provided to medicare beneficiaries and helping hospitals maintain compliance with the Medicare conditions of participation.
Admission necessity, coding and quality of care QIPs are initiated through pattern analysis.