Forced to arrange for the needs of their elderly patients, physicians often over-utilize SNF placement for patients who need assistance but who do not require high-level services provided by SNFs. One such example was a 2003-2004 study of Wisconsin hospitals revealing that half of all three-day hospital stays preceding SNF admission were found to be medically unnecessary. In order to contain costs and avoid overutilization of SNFs, Congress enacted requirements to ensure limited access to SNF to those with medical need. These requirements include: a physician’s order for a “skilled” level of nursing or rehabilitation care that can not be provided at home or as an outpatient, a requirement that daily inpatient care is medically necessary, a 3-day qualifying hospital stay in the 30 days prior to entering the SNF, and evidence that the SNF services were started and are for a medical condition related to that 3-day admission . Forced to be gatekeepers for the medical system, ED physicians frequently admit elderly patients to initiate the 3-day hospitalization with the goal of facilitating long-term placement. While CMS assumes physicians use their best discretion to determine medical need when deciding which patients to hospitalize, there is a Medicare claims review mechanism to check for cases of fraud.
In order to get the LTC that physicians believe their patients need, their decision to admit for a 3-day stay may be teetering in a gray area of “medical necessity” as defined by law. In 2003 the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) directed the Centers for Medicare and Medicaid Services (CMS) to create a three-year Recovery Audit Contractor (RAC) demonstration program to detect and correct improper payments in Medicare in three states. One of the “target areas” for the RACs was three-day stays to qualify for SNF care. At the conclusion of the demonstration project in 2008, 85% of the total overpayments collected by the RACs were from inpatient hospitals, with 62% of those provider errors being termed as “medically unnecessary service or setting,”. The Tax Relief and Health Care Act of 2006 made the RAC program permanent and authorized CMS to expand the program to all 50 states by 2010 . Currently RACs and Quality Improvement Organizations use auditing criteria like the Interqual™ Level of Care Determination Tools to review the necessity of admissions and to recover the payment for medically unnecessary admissions even if the hospital already billed and collected for services rendered.
In formulating the language for health care reform, policy makers including President Obama have pointed to cracking down on fraud and abuse in order to help cut out the waste and high costs in Medicare. It is certainly admirable to promote efficiency and transparency in a system where so much of our public dollars are spent. However, the danger could be an issue of distinction: choosing to either fix the system or to preemptively control and micromanage every medical decision through government oversight. Already, one state has decided to use the latter approach.
In 2007, Minnesota enacted a requirement that an Inpatient Hospital Authorization (IHA) must be obtained by a state medical review agent before admitting a patient to inpatient services. The medical review agent uses the “Appropriateness Evaluation Protocol” (AEP) from the National Institutes of Health as their guide to determining medical necessity. This was seen as a preemptive approach to ensure that patients who are admitted truly have a medical necessity and are not just being admitted to qualify for SNF care for example. But is this the future of health care reform? ED physicians need to be proactive and work to remain compliant with Medicare policy as well as put pressure on policy makers to eliminate barriers to necessary care like the 3-day stay requirement for SNF care.
Despite the possible grim outlook in the face of the nationwide RAC expansion, ED physicians must be proactive in advocating on behalf of their patients. It is important to comply with federal regulations, yet ED physicians should not be forced to act as gatekeepers for a medical system that is inadequately caring for its constituents. We must become an active part of health care reform efforts that will better address the needs of our geriatric population. Finding a way to avoid the ED altogether and bypassing or streamlining the inpatient stay requirement will serve to reduce over-utilization. Expanding the CMS Program of All Inclusive Care for the Elderly (PACE)  could serve to provide the integrated and transitional care coordination that often helps the elderly remain independent and receive higher quality of care, as opposed to the episodic acute care under the current system.
Policy efforts should focus on preemptive planning for assisting elderly patients in the outpatient setting as well as providing alternative options to SNF placement in the acute setting. Changing current practice will decrease costs, provide better care for elderly patients requiring long-term placement, and prevent physicians from practicing fraudulent medicine. In this time of healthcare reform with attention on combating fraud and abuse, we must ensure that change serves to benefit the elderly rather than trimming dollars at their expense.
1. Uninsured, K.C.o.M.a.t., Private Long-Term Care Insurance: A Viable Option for Low and Middle-Income Seniors? Citing AHIP LTC Insurance Market Survey, 2002, 2006.
2. §1861(i), Social Security Act.
3. The Medicare Recovery Audit Contractor Program: And Evaluation of the 3-Year Demonstration. 2008.
4. 6111, Tax Relief and Health Care Act 2006.
5. ACEP. Utilization Review FAQs.
Http://www.acep.org/practres.aspx?id=36598. Accessed April 30, 2009.
6. CMS, Program of All Inclusive Care for the Elderly (PACE). 2009.
Cover Story//Geriatric Emergency Medicine
compliant with federal guidelines
(so you can stay out of jail)
1. Make decisions to admit on patients’ medical condition
2. Carefully document the full clinical presentation ( including social conditions and co-morbidities
3. Document why it is not safe to discharge the patient home and the risks associated with discharge
4. Invite a representative from utilization management to speak with the ED group about medical necessity admission criteria to enhance appropriate documentation
5. When appropriate use observation admissions rather than inpatient admissions
6. Hire utilization review specialists assigned to the ED to review medical records before patient discharges/transfers to ensure compliance with CMS admission criteria (eg using InterQual or other clinical decision support tools will assist during audits)
7. Audit bills before they are submitted
8. Extend hours of case managers and social workers and open communication with elder care coordinating organizations to assist with LTC placement from the ED
9. Routinely review admissions that result in less than 24 hour stays and admissions denied reimbursement by Medicare.