WHEN MEDICARE LAUNCHED its two-midnight rule last fall, Mary Frances Barthel, MD, thought she had it all figured out.
As director of the Cogent Healthcare hospitalist program at Blessing Hospital in Quincy, Ill., Dr. Barthel spent a great deal of time hammering the point home that under the new rule, doctors' expectations of how much time patients would need in the hospital would determine whether they would be admitted or placed in observation.
No longer, as Dr. Barthel
understood it, would she
colleagues have to parse out admission criteria in commercial
"We did a big blitz around the Oct. 1 kickoff," says Dr. Barthel
"We had a medical staff meeting, mailings and one-on-one education with physicians who admit a lot of patients.
We came up with a really good synopsis of the final rule and advice on what to do."
But six months later, Dr. Barthel
has had to circle back to those same doctors with a different approach.
"The more we heard from the advisory company, the less confident we were saying that time was the most important factor," says Dr. Barthel
"Lately, we've gone back to using InterQual
to answer whether the patient's presenting problems meet medical necessity for inpatient admission, and then we also ask the physician to predict how long he
expects the patient to be in the hospital."
group now bills many more ICU patients as observation than they did before Oct. 1.
As for the rest of the one-midnight inpatient stays, "I get the impression that the advisory company believes such stays should basically never happen," says Dr. Barthel
Or should they-like Dr. Barthel
colleagues- still rely on admission criteria that may (may!) provide some protection once recovery audit contractors (RACs) start tackling claims?
"It used to be that outpatient physicians who admit their own patients could just fax an order to the admitting office, but we no longer allow that," says Mary Frances Barthel, MD, director of the Cogent Healthcare hospitalist program at the hospital.
Instead, a representative from the physician's clinic has to call one of the hospital's utilization nurses to discuss the patient's status and expected length of stay.
For outpatient physicians covered in the hospital by hospitalists, that's now a two-step process: The outpatient physician has to call the hospitalist, who then calls a utilization nurse.
"That order used to be a fax before," says Dr. Barthel
"Now, it has to be a phone call."
Then there's this innovation: Dr. Barthel, who's also the hospital's utilization management physician advisor, has designed two versions of the letter sent to the attending physician when an admission is downgraded to observation status before discharge.
"One version says, 'Your patient did not meet medical necessity requirements so was changed to observation,' " she