Jeffrey Rakover, Cardiovascular Roundtable
Many institutions still struggle with increased pressure to bill traditionally inpatient care on an outpatient basis. The RAC audit program continues to be controversial in some quarters, even if it’s accepted as an unfortunate fact of life in others.
The most recent proposed inpatient rule only exacerbates the pressure to accurately triage patients between inpatient and outpatient, proposing that patients be in the hospital for at least two midnights to qualify as true inpatients.
The Roundtable has produced a number of resources bearing on the question of increased scrutiny of inpatient stays and the shift toward outpatient payment. Here, we’ve compiled our tools and publications for programs to effectively navigate these pressures.
The resources include triage criteria, case studies and insights to optimize observation status, and strategies to decrease length of stay for procedures where actual care patterns lag behind payment categorization.
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Hospitals Report Negative Financial Ramifications from Using Observation Status
As featured in the Daily Briefing, Medicare and private insurers are increasingly labeling patients as "observation cases," or outpatients, despite days-long hospital stays, a practice that is boosting costs for facilities and patients, the Pittsburgh Tribune-Review reports.
Although the observation label is not new--CMS applies the designation to patients admitted through the ED with symptoms that can be stabilized within 24 hours, such as asthma and chest pain--hospital leaders in Pennsylvania say the practice of classifying cases as outpatient despite longer hospital stays has grown and is burdening facilities with lower reimbursement. Federal law does not specify that a patient must be considered an inpatient admission after 24 hours in a hospital, according to a Medicare spokesperson. Payment for an observation case is 33% of payment for an inpatient admission, according to the CMO at Forbes Regional Hospital. The trend can also be particularly harmful to Medicare patients because it may lead to denied coverage for nursing home care, the Tribune-Review reports.
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