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News to Note – November 2021

  • The oral antiviral medication for COVID is soon going to the FDA for Emergency use authorization. The actual study data is not available, but we know that the review board stopped the study early because the results were better than expected. It’s unclear what the medication will cost and whether the government will pay for it as they do for the vaccine and other COVID treatments. There are other questions about how it will be distributed so it gets to the people who need it most. And it goes without saying that if everyone gets the vaccine and we reach herd immunity, it decreases the need for this medication.
  • Recently a study was published where researchers looked at over 500 health systems across the country and how often patients who receive primary care from their network receive low value medical care. They chose 41 services as low value, including such services as repeating bone density scans at an interval of less than 2 years, doing routine preoperative EKGs or stress tests, doing PSAs in men over 70, doing carotid artery scans in patients with syncope, etc. They then used a sophisticated statistical analysis to rank the health systems. They even provided the list of rankings. Keep in mind, studies like this are inexact because patients may receive care from doctors in multiple health systems but they can only be attributed to one. If their primary care physician does little low value care but their specialist across town who is affiliated with another system orders a bunch of low value tests and treatments, the primary care physician’s health system takes the hit. The study also uses only claims data and not chart review so the actual indication may have been documented but not coded. Nonetheless, you should consider looking up your health system here. Even if you are not interested in your system’s performance, you should look at the list of low value care services in the paper and keep an eye out for them in your facility.
  • Blue Cross of Michigan released a notice that starting in 2022, they will not approve inpatient admission for a list of 22 diagnoses until at least 48 hours of observation has passed unless the patient was receiving care in the ICU. While some of the diagnoses might make sense, like syncope and nausea and vomiting, the list also includes all patients with heart failure, COPD and pneumonia, diabetic ketoacidosis, and amazingly meningitis. They also note that InterQual criteria will not be used until after that 48 hours has passed. So if your acute exacerbation of systolic heart failure patient also has acute kidney injury, hyponatremia, and metabolic encephalopathy, and you know they will need at least 3 or 4 days, and the light turns green in InterQual, unless you admit them to the ICU, they are Observation.
    • Of note, Blue Cross implies that this applies to all their plans but it is unclear if it applies to their Medicaid product. Dr Eddie Hu, the system physician advisor at UNC Health, has pointed out a crucial section of the code of federal regulations, 42 CFR 440.2. That section describes the federal financial participation in Medicaid programs, and it clearly defines an inpatient as a patient who has been hospitalized over 24 hours or is expected to need 24 hours. It is not 48 hours, it is not 24 to 48 hours. There is no mention of criteria. And this is a regulation, not a manual or FAQ. This appears to mean that every single Medicaid plan in the country, including Managed Medicaid plans, must abide by this definition of inpatient if they want the federal money. All of you may want to look at your Medicaid plan rules and remind them that they violate federal regulations at their own risk.
  • Recently Medscape reported on how Anthem, another Blue Cross product, has started to analyze physician claims and automatically downgrade office visit codes. As with United Healthcare, Anthem would not provide any notice or explanation but simply pay the claim at a lower rate. For example, if the physician submitted a level 4 visit, it would be paid at a level 3 rate. When asked, Anthem stated they use “analytical tools” during claims processing. They also stated that physicians can dispute the downgrades by “supplying a statement explaining why they disagree with the decision along with documentation to support their statement.” For one doctor, the payment difference amounted to $18 per claim. For the physician, $18 on each claim adds up and at the same time the cost to prepare the statement and documentation to dispute the downgrade would probably cost more than $18. Medscape also discussed the Kaiser report of payers slowing down payments to providers and profiting from the float.
  • In other news, First Coast Service Options, one of the MACs, released an update to their frequently asked questions about guidance for hospital admission decisions and they referred readers to a CMS MLN Matters from 2012. Unfortunately, the 2 Midnight Rule did not exist in 2012 which makes that less applicable.
  • A reminder that the COVID-19 public health emergency declaration was renewed for another 90 days on October 18th. The declaration extends all the COVID-19 waivers including the requirement to offer patients choice of a post-acute care provider and the 3-day inpatient stay requirement. Of course, some nursing homes are continuing to refuse patients without that 3-day inpatient stay as is their right. With so much scrutiny on nursing homes during this pandemic and the terrible staffing shortages they are facing, it’s not hard to understand why they may be worried about admitting a patient where they think they won’t get paid. But their reluctance also means a patient who does not require hospital care is occupying a bed that could be used by a patient who needs it. As a reminder, don’t forget that many rural hospitals have swing beds and would be glad to accept your patient for rehabilitation.

**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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