Taking a closer look at updates to the inpatient-only list, price transparency

Wednesday, March 3, 2021

On the latest episode of The Revenue Integrity Show: A NAHRI Podcast, listeners were treated to in-depth discussions on two of the hottest topics in the industry — updates to the inpatient-only list and price transparency.

Ronald Hirsch, MD, FACP, CHCQM, vice president, R1 Physician Advisory Services in Chicago led off the February 25 podcast with a presentation on the inpatient-only list. He was followed by Caroline Znaniec, managing director, CohnReznick LLP’s Healthcare Advisory Practice in Baltimore, Maryland for an overview of price transparency requirements.

Hirsch began his portion of the show by reinforcing an important point: If surgeries are not on the inpatient-only list, that does not mean they must be done as outpatient.

“I know that sounds obvious, but we’re still hearing from hospitals that say, ‘We’re just having doctors put everybody as outpatient,’” Hirsch said. “The problem with that of course is that you’re potentially leaving tons of compliant revenue on the table.”

Hirsch pointed out that for some spine surgeries the differential between inpatient and outpatient is between $10,000–$15,000 per surgery.

“That’s a lot of money at stake,” Hirsch said. “And if you can compliantly admit them as an inpatient, then you absolutely want to do that.”

For surgeries that are off the inpatient-only list, organizations must apply the 2-midnight rule. Hirsch highlighted three factors to consider during this process:

  • 2-midnight expectation: A patient who is having bypass surgery will need two midnights in the hospital, Hirsch said. But there will other surgeries, such as joint replacement, where it’s not necessarily so clear. While the standard now is that joint replacement patients go home within a day or so, the 2-midnight expectation can be made for specific patients if the physician documents the reason the patient needs to stay.
  • 2 midnights pass: When a patient is expected to go home the day after surgery, but they’re not feeling well enough (i.e., still in pain, not eating, nauseous, delirious, suffering from a medical complication), they’ll need to stay more than two midnights.

“They obviously can be admitted as an inpatient, but we want to make sure the documentation is there,” Hirsch said.

The surgeon cannot simply write “continue post-op care.” The reasons for the continuation of care must be documented, Hirsch said.

  • 1-midnight expectation but high risk: In 2016, Medicare added to the 2-midnight rule the exception for a patient with a 1-midnight expectation, but who is at high risk or surgery. Although Medicare states that they’re putting this exception under the category of rare and unusual, they do not expect these situations to be rare and unusual, Hirsch said. Organizations should use it as often as clinically appropriate. The following two risks should be considered, according to Hirsch:
    • The surgical risk
    • The medical co-morbid conditions contributing to an increased risk

Again, documentation is paramount. Doctors should be using language like “due to this patient’s diabetes and heart disease, they require inpatient admission due to a higher risk of surgery” in their documentation, Hirsch said.

“If that’s there, I think your cases are defendable to be an inpatient,” Hirsch said. “You’re going to be using more resources, even though the length of stay is the same, it justifies inpatient admission by Medicare rules. So, work with your doctors, talk about documentation, come up with some risk stratification, and get the compliant revenue that you deserve.”

Hirsch then turned the show over to Znaniec, who provided a detailed assessment of the price transparency changes, including an overview of common areas of noncompliance that are trending across hospitals. Those areas include:

  • Organizations providing either a comprehensive machine-readable file or a shoppable services display, but not both. “More so we’ll see a patient estimation tool or the shoppable service piece but not see the comprehensive file because that’s the biggest lift,” Znaniec said. “It’s really hard. There’s a lot of information to get. And there’s a feeling out there from many hospitals and administrations that if we’re truly trying to get to the objectives of being patient-centric and helping them with an estimation of what’s out of pocket, the priority should be more so on the shoppable services and less so on this larger file that’s not really intended to be for the public.” Nevertheless, both are required for compliance.
  • Not including all data elements. If Znaniec were auditing an organization, the first thing she would look for is package service items. “If I look at your comprehensive file and I don’t’ see a line item by DRG, then that’s something that is going to pique my interest and I may say, ‘if that’s missing, what else could be missing?’” Znaniec said.
  • Not providing payer-negotiated rates. This is fairly common, Znaniec said. An example would be an organization listing just the minimum and maximum charge and not giving information down to the plan, such as Aetna PPO versus Aetna HMO versus Aetna commercial, but simply listing “Aetna”.

For more information on the inpatient-only list and price transparency, check out last week’s podcast.

NAHRI is currently seeking guest speakers for its May and June podcast episodes. Guests are encouraged to submit topic ideas so they can share their expertise with the audience. If you are interested in making an appearance on the Revenue Integrity Show, contact us at nahri@hcpro.com.