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News to Note – May 2021

  • A recent case was presented of a patient who had commercial insurance from United Health Care (UHC) who was admitted as inpatient. Of note, the inpatient admission was approved by UHC. During that stay, it was determined that the patient required a pacemaker and one was placed. After discharge, UHC denied the physician claim for placement of the pacemaker stating that prior authorization was required. This led to a deeper look at UHC policies and of note, UHC requires notification for any electrophysiology implant, even on inpatients.
  • Recently the Office of the Inspector General (OIG) released the results of an audit of a Las Vegas Hospital with a focus on Inpatient Rehab admissions and had a high denial rate. And like the past IRF audits, the hospital strenuously objected to the findings because they were admitting seriously ill patients, caring for them, and meeting the IRF documentation requirements. The hospital called into question the qualifications of the reviewer, but the OIG defended that person by stating that not only were a physical medicine physician but that they were “steeped in knowledge of Medicare IRF requirement.”
  • A recent RACmonitor article discusses patients who stay overnight after an outpatient surgery. The article suggests that physicians who do this are keeping their patients only because that is what they are comfortable doing and that it is never medically necessary. However, while we are getting much more efficient and stays are shorter, there is a safe limit. But, keeping the patient overnight and calling that observation or inpatient is wrong. It is routine outpatient recovery and there is no additional revenue for that. Please don’t read this and go tell your surgeons that every outpatient must go home the same day. If they require hospital care overnight, they can stay as outpatient.
  • Reference pricing may be a way to keep costs down for orthopedic and spine surgeries.
    • These are costly surgeries because of the cost of the hardware that is implanted
    • In the past, there were efforts to use collective bargaining power to negotiate prices by trying to get all physicians to agree to use the same implants despite physician dissatisfaction with this.
    • Another method to keep costs down is reference pricing which involves the hospital setting a price they think is reasonable and then telling every manufacturer that their products can be used if they agree to that price. This keeps a more reasonable cost while also keeping physicians happy by allowing them choices.
  • The Center for Medicare and Medicaid Services (CMS) is again allowing survey agencies to do in-person hospital surveys.
    • However, CMS has said that hospitals are not allowed to refuse entry to unvaccinated surveyors.
    • CMS also is adding a quality measure to several of the 2022 proposed rules measuring the rate of vaccination of the healthcare personnel in the organization, thereby holding these organizations responsible for ensuring their staff is vaccinated.

**The news above in addition to many other points of interest for Physician Advisors and other leaders in health care can be heard weekly during Dr. Ronald Hirsch’s Monday Rounds segment on’s Monitor Monday webcast/podcast. Learn More

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