CMS and Discharge Planning Conditions of participation


Hospitals are advised to provide a choice for patients in terms of nursing homes, home care agencies, acute long-term care hospitals and inpatient rehabilitation facilities.

It has now been more than 18 months since the Centers for Medicare & Medicaid Services (CMS) updated the terms of participation in discharge planning, but we still do not have interpretive guidelines. I’m sure the pandemic has affected this, but as many of you know firsthand, in-person investigations have resumed, so it would be nice to have this advice on what CMS really expects from hospitals.

But the rule itself has a few things that can help, meanwhile. First, CMS has spoken repeatedly about meeting patient goals of care and treatment preferences. And when they talk about something so enthusiastically, you know they really want to make sure it gets done. So make sure your staff talk to patients about these factors and document that they have discussed them.

We also know that CMS is expecting another big thing; Once the public health emergency (PHE) is over, you had better offer your patients a choice in terms of nursing homes, home care agencies, long-term care hospitals, and nursing homes. ‘inpatient rehabilitation facilities, as well as providing quality measurements and data.

This brings me to an interesting question I was asked last week on the issue of patient choice. This west coast hospital, located in an area with a very large Medicare Advantage (MA) population, allows case managers employed by some high payers to come to the hospital and meet with their beneficiaries, with their consent. and they are the ones who make all discharge plans with the patient, not with the hospital case management staff.

So the question for me was, should the payer‘s case manager offer full choice to their own patients, or can they just offer contracted providers? While I didn’t get a definitive answer immediately, here’s what I think.

First, while the hospital is free to let the hospital payers make these arrangements, it remains the hospital’s responsibility to ensure that the conditions for participation are met. This means that the discussions between the payer and the patient must be documented in the medical record. Second, Medicare expects every patient to have full choice, and makes no exceptions in the rules or advice for AD patients. I think the MA patient can receive the list of contracted providers, but should at least also be informed that he can choose any provider (but that he would probably be responsible for the cost if he chooses a non-contracted provider) . Now, how does this hospital go about making sure that happens? I have no idea, but I would be sure to find out before the PHE expires.

But that wasn’t the only tough question that came up that week. One provider received a refusal from its Medicare Administrative Contractor (MAC) stating that it was recovering money for “a medical necessity refusal for an inpatient issued by the QIO (Quality Improvement Organization)”.

The problem was, they had no other information. The denial person searched and searched and found nothing. They called the MAC and Livanta the QIO of Client and Family Centered Care (BFCC-QIO) which now audits all short stay and highly weighted DRGs for the nation, and they too have not been of no help; the MAC referred them to the QIO, which had no information.

Needless to say, they will continue to seek an answer. But one thing came from this research. The hospital realized that when Livanta took over from Kepro this month as BFCC-QIO, the hospital never signed a Memorandum of Understanding (MOA) or provided mailing addresses. preferred for registration requests. So, one possibility is that the denial was issued because the case was selected for audit and then either the registration request never arrived at the hospital’s Health Information Management (HIM) department. , so the records were never sent, or Livanta didn’t have a valid MOA, so they never even sent an Additional Documentation Request (ADR).

The lesson here for the half of the country that had Kepro as BFCC-QIO is if you have a new MOA with Livanta – and if they have the right contact information. You don’t want to have to go through what this hospital is going through.

Programming note: Hear Dr. Ronald Hirsch perform his Monday rounds at Monitor Mondays, 10 Eastern, sponsored by R1 RCM.


Previous Payer Compass Appoints Doug Williams to Board of Directors
Next My long-awaited education on residential schools