1. April 2010 UTILIZATION REVIEW HOW TO GET PAID (CORRECTLY) FOR PROVIDING CARE AND SERVICE

2. April 2010 OVERVIEW  UR Plan  Tasks  Patient Status  Patient Rights  Notices  Tools  References

3. April 2010 PLAN  Committee  Scope and frequency of review  Staffing  Criteria  Determinations regarding admissions or continued stays  Extended stay review  Performance improvement

4. April 2010 TASKS  Observation  Payer source  UR line  Criteria  Length of stay  Quality CMS measures Present on admission Hospital-acquired infections

5. April 2010 OBSERVATION  Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.  Postop amb surg: 4-6 hours of recovery, unplanned outcome or exacerbation of a condition; other wise extended recovery

6. April 2010 INPATIENT  The physician is responsible for deciding whether the patient should be admitted as an inpatient; should use a 24-hour period as a benchmark; requires complex medical judgment and consideration of a number of factors  Severity of illness and intensity of service  Benefit period: 60F + 30C > 60O (+ 60L)

7. April 2010 SWING BED  3 day qualifying stay  30 day window  Benefit period: 20F +80C > 60O  Physician certification on admission  Recertification day 14, day 44, day 74  Related condition, daily skilled need, inpatient setting, reasonable & necessary

8. April 2010 SWING BED – examples of skilled services  Nursing Management & evaluation of a patient care plan – require the involvement of skilled personnel to meet patient needs Observation & assessment of patient’s condition – when there is a likelihood of change in patient condition Teaching & training activities – injections, new diabetic, care of dressings or skin treatments, care for central lines, self-catheterization, colostomy care, gastrostomy feedings, prosthesis care Direct skilled nursing – IV therapy, Stage 3 or > pressure ulcer treatments, dressings involving aseptic technique  Therapy Based on eval by qualified PT; require judgment, knowledge, skills of PT; potential for patient improvement over reasonable period of time; specific & effective for patient condition; reasonable & necessary amount, frequency, & duration Examples: Assessment, therapeutic exercises, gait training, range of motion, maintenance therapy, Ultrasound, shortwave, and microwave diathermy treatments, Hot packs, Infra-Red Treatments, Paraffin Baths, and Whirlpool Baths, Speech-Language Pathology, Occupational Therapy

9. April 2010 SWING BED – Medicaid  If MA is primary or secondary, prior authorization is required  Must transfer to NH unless no skilled NH bed available within 25 miles OR physician may request waiver in writing if: Transfer would endanger patient OR Life expectancy is 6 months or less  Level of Care & Level I forms to MPQH  Waiver request to Senior & LTC Division

10. April 2010 MEDICAID – Mental Health  Verify MA eligibility (Mental Health Access Program does not cover – 72 hr presumptive eligibility program available if no pay source)  Notify First Health Services (https://montana.fhsc.com) – prior authorization request form within 1 business dayhttps://montana.fhsc.com  Under age 21: Certificate of Need within 14 days  Discharge form within 5 business days after discharge

11. April 2010 MEDICAID – Alcohol & Drug Detox  Limited to 4 days unless necessary adjunct to treatment of a concomitant condition  Obtain authorization by contacting DPHHS RN Case Manager

12. April 2010 COMMERCIAL PAYERS  “Swing Bed” rates can be negotiated with some commercial payers Patient’s policy needs to cover skilled care services  No prior authorization is required in connection with childbirth for a mother and her newborn; 48 hour postpartum vaginal delivery; 96 hour postpartum c- section

13. April 2010 INPATIENT HOSPICE  Respite Care - short-term inpatient care to relieve caregivers at home - only on an occasional basis - no more than 5 consecutive days at a time  General Inpatient Care – may be required for procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings

14. April 2010 CHANGING PATIENT STATUS  IP to Observation Medicare: prior to discharge, no claim submitted, physician concurs, concurrence is documented  Can only bill from the time the observation orders are written (condition code 44)  Must notify patient Commercial: variance order  Observation to IP Precertification required for commercial IP stay

15. April 2010 MEDICARE DISCHARGE APPEAL RIGHTS  “Important Message from Medicare” Within 2 days of admission AND discharge Signed original to patient, copy to record May use same notice for initials at discharge  “Detailed Notice of Discharge” Deliver to patient no later than noon of the day after the QIO notification to the hospital

16. April 2010 MEDICARE NOTICES  OBSERVATION When otherwise covered services will be noncovered If services will no longer be reasonable or necessary ABN (Advanced Beneficiary Notice) given prior to service

17. April 2010 MEDICARE NOTICES  INPATIENT Given when care not medically necessary, not delivered in the most appropriate setting, or is custodial in nature  HINN 1 (preadmission/ admission)  HINN 10 (Hospital Requested Review – HRR) without physician concurrence  HINN 11 (non-covered items or services during an otherwise covered stay)  HINN 12 (non-covered continued stay)

18. April 2010 MEDICARE NOTICES  SWING BED “Notice of Medicare Provider Non-Coverage” – at least 2 days prior to discharge “Detailed Explanation of Non-Coverage” – when QIO review is requested Notice of Exclusions from Medicare Benefits (no qualifying 3 day hospital stay, no days left in benefit period, daily skilled care requirements not met) – HINN or NEMB?

19. April 2010 DOCUMENTATION - provider  Physician: take care of patients and document well  Documentation requirements: OP Treatment: Dx, Tx OP Procedure: if pt not ready after 6 hrs routine recovery, order extended recovery or Observation (or IP) Observation: Reason for observation, tests, txs, monitoring parameters, decision point (intervene -> assess -> discharge or IP or intervene -> etc) IP: severity of illness, intensity of service SB: response to skilled care Hospice Acute: pain and symptom control

20. April 2010 DOCUMENTATION - nurse  Nurse: take care of patients and document well  Documentation requirements: OP Treatment: patient care and responses OP Procedure: if pt not ready after 6 hrs routine recovery, get order for extended recovery or Observation (or IP) Observation: tests, txs, patient response, communication with physician IP: severity of illness, intensity of service SB: response to skilled care Hospice Acute: pain and symptom control

21. April 2010

37. REFERENCES  42CFR § 482.30 Medicare Conditions of Participation Standards for Hospital Utilization Review http://edocket.access.gpo.gov/cfr_2004/octqtr/pdf/42cfr482.3 0.pdf  Medicare Benefit Policy Manual, Chapter 1 - Inpatient Hospital Services Covered Under Part A http://www.cms.hhs.gov/manuals/Downloads/bp102c01.pdf  Medicare General Information, Eligibility, and Entitlement, Chapter 4 - Physician Certification and Recertification of Services http://www.cms.hhs.gov/manuals/downloads/ge101c04.pdf

38. April 2010 REFERENCES  Medicare Benefit Policy Manual, Chapter 6 - Hospital Services Covered Under Part B http://www.cms.hhs.gov/manuals/Downloads/bp102c06.pdf  Medicare Benefit Policy Manual, Chapter 3 - Duration of Covered Inpatient Services http://www.cms.hhs.gov/manuals/Downloads/bp102c03.pdf  Medicare Benefit Policy Manual, Chapter 8 - Coverage of Extended Care (SNF/SB) Services Under Hospital Insurance http://www.cms.hhs.gov/manuals/Downloads/bp102c08.pdf

39. April 2010 REFERENCES  Medicare General Information, Eligibility, and Entitlement, Chapter 3 - Deductibles, Coinsurance Amounts, and Payment Limitations http://www.cms.hhs.gov/manuals/downloads/ge101c03.pdf  ARMs 37.40.4 Swing Beds http://www.mtrules.org/gateway/Subchapterhome.asp?scn= 37%2E40%2E4  Montana Medicaid http://www.dphhs.mt.gov/programsservices/medicaid.shtml

40. April 2010 REFERENCES  ARMs 37.88.11 : Medicaid Mental Health Services: Inpatient Psychiatric Services http://www.mtrules.org/gateway/ChapterHome.asp?Chapter =37%2E88  ARMs 37.86.29 Medicaid Primary Care Services: Inpatient Hospital Services http://www.mtrules.org/gateway/Subchapterhome.asp?scn= 37%2E86.29  FHSC Montana Adult Acute Inpatient Provider Manual, Version 2.1, December 1, 2008 https://montana.fhsc.com/Downloads/Adult/manuals/MT_A_ Acute_ProviderManual_2_1-20090506.pdf

41. April 2010 REFERENCES  Newborns’ and Mothers’ Health Protection Act http://www.dol.gov/federalregister/HtmlDisplay.aspx?DocId= 21637&AgencyId=8  Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance http://www.cms.hhs.gov/manuals/Downloads/bp102c09.pdf  Medicare Claims Processing Manual, Chapter 30 - Financial Liability Protections http://www.cms.hhs.gov/manuals/downloads/clm104c30.pdf

42. April 2010 REFERENCES  CMS Home > Medicare > Beneficiary Notices Initiative (BNI) > Hospital Discharge Appeal Notices http://www.cms.hhs.gov/BNI/12_HospitalDischargeAppealN otices.asp#TopOfPage  CMS Home > Medicare > Beneficiary Notices Initiative (BNI) > Overview http://www.cms.hhs.gov/bni/  CMS Home > Medicare > Beneficiary Notices Initiative (BNI) > FFS Revised ABN http://www.cms.hhs.gov/BNI/02_ABN.asp#TopOfPage

43. April 2010 REFERENCES  CMS Home > Medicare > Beneficiary Notices Initiative (BNI) > FFS HINNs http://www.cms.hhs.gov/BNI/05_HINNs.asp  CMS Home > Medicare > Beneficiary Notices Initiative (BNI) > FFS ED Notices http://www.cms.hhs.gov/BNI/06_FFSEDNotices.asp#TopOf Page  CMS Home > Medicare > Beneficiary Notices Initiative (BNI) > FFS NEMB SNF http://www.cms.gov/BNI/13_FFS%20NEMB%20SNF.asp#T opOfPage