CMS proposed rule impacts how hospitals determine LOS for MA patients The Centers for Medicare and Medicaid Services (CMS) recently proposed rule changes (CMS-4201) that could have a significant impact on how hospital utilization management determines level of care for Medicare Advantage patients. The proposed rule1 reflects the agency’s focus on increasing transparency, improving health …
UnitedHealthcare’s Observation Utilization Review Guide is sunsetting and will be replaced by the new Hospital Services: Observation and Inpatient Policy1. The change takes effect Dec. 1, 2022, for commercial, community and exchange plans. The new policy explicitly mentions InterQual, stating “InterQual criteria are intended to be used in connection with the independent professional medical judgment …
New UHC Hospital Services Observation and Inpatient Policy takes effect Dec. 1, 2022 Read More »
Both national evidence-based guidelines and insurance company guidelines factor into level of care determination. When it comes to determining a patient’s level of care for a short hospital stay, observation services are generally used for short-term monitoring, testing and evaluation to establish a treatment plan, and to give the treatment team time to see …
Which guidelines should hospitals follow for an observation stay? Read More »
The United States Department of Justice filed an antitrust lawsuit earlier this year aiming to stop UnitedHealth Group from acquiring Change Healthcare.1 Hospital CFOs and utilization review managers have much to watch in this case related to how it could not only impact competition in the markets but how it could impact the guidelines used …
We all know in clinical medicine that documentation is everything. Hence the old saying “If it’s not documented, then it didn’t happen.” This is particularly true outside of the clinical realm in the insurance world. Level of care is based on the clinical condition of the patient, how they present and how that meshes with …
Good documentation can reduce hospital admission denials Read More »
As hospitals in some areas face a new and devastating round of COVID-19 surges, the financial impact on those hospitals is not yet known. This new spike in cases comes on the heels of more than 16-months of instability caused by the pandemic and just when hospitals were starting to make gains financially. According to …
After what must have been significant feedback, the Centers for Medicare & Medicaid Services is now reversing its move to eliminate the inpatient only (IPO) list in 2022 and add back the 298 services removed from the IPO list in 2021. 1 If this goes through in 2022, it will require hospitals to be extra …
For an update on this issue, please read: CMS reverses course in inpatient only list The Centers for Medicare & Medicaid Services (CMS) has begun to dismantle its inpatient only list, which has directed the level of care for more than 1700 procedures for physicians and hospitals since 2000. CMS said the move gives physicians …
Eliminating the CMS inpatient only list will continue to complicate hospital stays Read More »
Utilization management programs are often in-house services provided by hospital staff. However, more and more hospitals are outsourcing utilization review management as the pressure mounts to contain costs, especially following the COVID-19 pandemic, and improve care. Hospitals benefit from outsourcing utilization review in several ways, as it can: Free up in-house physician advisors and chief …
There is one relatively easy way hospitals can reduce claims denials: better clinical documentation. Insurance companies require documentation, and it is often the leading factor in level of care and admission denials. The importance of providing complete documentation never goes away. Treating physicians and utilization review managers must ensure that every admission includes: All the …