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SAVING LIVES BY DISCHARGING PATIENTS – AND A QIO SKIRTING THE RULES

 * By Ronald Hirsch, MD, FACP, CHCQM, CHRI
 * November 15, 2023

We often talk about length of stay, and you all should know by now that I
absolutely hate when the Medicare geometric mean length of stay (GMLOS) is used
as a goal for every patient in each Diagnosis-Related Group (DRG).

I’ll repeat my mantra: the goal length of stay for every patient is when every
single day of their hospital stay is spent providing medically necessary
hospital care. If they don’t require hospital care, they shouldn’t be in the
hospital.

Well, last week saw the publication of another article that demonstrates the
importance of reducing avoidable days. This study looked at patients 75 years of
age and older who were admitted to the hospital but were required to be kept in
the ED overnight due to the lack of an inpatient bed. Compared to patients who
did not have to board in the ED, the boarded patients had a 41-percent higher
risk of dying in the hospital, more adverse events (including falls and
nosocomial infections), and longer overall lengths of stay.

Now, this data is probably not a surprise to anyone, but sometimes you do need
data to motivate change. Maybe it’s worth risking a bad patient satisfaction
score from the patient upstairs who wants to stay another day but has no medical
necessity, in order to save another patient from harm or even death.

Moving on, Kepro, the Quality Improvement Organization (QIO), released their
November newsletter, which included what they called an immediate advocacy
success story. In this case, it was an inpatient who was not happy with the
attending physician and their impending discharge, so their representative filed
a discharge appeal. Kepro ruled in favor of the patient. As Kepro describes it,
“However, in the appeal determination provided to the facility, the Kepro peer
reviewer had requested a neurological consult, but the attending physician at
the hospital refused to do the consult and wrote another discharge order.”

Kepro states that they then contacted the hospital director of quality and
patient safety, who then contacted the patient’s case manager to discuss the
request for the consult by the Kepro reviewer with the attending.

Wait a minute. First, this started as a discharge appeal. In a discharge appeal,
the QIO is supposed to determine if ongoing hospital care is warranted, not
whether additional consultations by specialists are required. Their reviewer
determined that ongoing hospital care was necessary, and the hospital and
attending complied. They likely did not issue the Hospital-Issued Notices of
Noncoverage (HINN) 12 and would not have charged the patient for the inpatient
days, awaiting the appeal determination. But when the determination was issued
and the attending informed, the attending apparently did not feel that a
neurology consultation was necessary, so they did not order one – and in
addition, they felt that at the point the appeal determination was received, the
patient was stable for discharge (so the attending again ordered discharge).

As Kepro describes it, this evolved into an immediate advocacy issue concerning
the quality of care provided by the physician, since that consultation was not
ordered. In that case, section 5035.3 of the QIO Manual requires the QIO to
contact the practitioner and give the practitioner an opportunity to
participate.

Kepro did no such thing. I would bet that, as at many hospitals, the attending
has no idea who the director of quality is, and yet Kepro considered that person
to be representing the physician’s views. We have all played the telephone game
as children; the likelihood that the information received and conveyed by the
attending physician matched what the QIO medical director said and heard is
small.

Now, don’t get me wrong: patients have a right to appeal their discharge and
request help through the immediate advocacy process provided by the QIOs, but
the QIOs really need to follow the rules, just as we do. In this case, it seems
that the QIO medical director should have called the attending physician to
discuss not only the rationale for the neurology consultation but also the
patient’s concern about their care.



 * TAGS: Case Management, Compliance, Medicare, Patient Care

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RONALD HIRSCH, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at
R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many
clinical leadership roles at healthcare organizations ranging from acute-care
hospitals and home health agencies to long-term care facilities and group
medical practices. In addition to serving as a medical director of case
management and medical necessity reviewer throughout his career, Dr. Hirsch has
delivered numerous peer lectures on case management best practices and is a
published author on the topic. He is a member of the Advisory Board of the
American College of Physician Advisors, a member of the American Case Management
Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a
member of the RACmonitor editorial board and is regular panelist on Monitor
Mondays. The opinions expressed are those of the author and do not necessarily
reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician
Advisory Services (R1 PAS).

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