Recently, several members of the staff have expressed concern about the impact of the Medicare (via the Centers for Medicare and Medicaid Services) coverage rules for post-acute care when a patient’s clinical needs do not require a three night inpatient stay. We understand that these Medicare and other insurance rules often put physicians in an uncomfortable position. One rule that is particularly troubling is the requirement for a three day inpatient stay before qualifying for skilled nursing care coverage.

The type of patient who falls between the cracks is often the chronically ill individual with some mild exacerbations of illness and is in need of medical care but is not quite sick enough to meet acute inpatient admission criteria. Other patients may have a cumulative total burden of illness that drives the family to bring the patient to the hospital due to caretaker exhaustion and being overwhelmed by the circumstances of the illnesses of a loved one. Your conscience as a physician may understandably make you feel compelled to get the patient admitted to the hospital to help the patient and family.

The fact is that frequently many of these scenarios do not meet Federal guidelines for inpatient admission to a hospital based on severity of illness or intensity of service criteria. This in turn may mean that Medicare will refuse to cover the admission as ‘medically necessary’ and thus subsequently also deny key post-acute care services coverage while simultaneously creating a difficult financial situation for patients and their families. With increasing scrutiny of hospitals to ensure “medical necessity” for inpatient admissions (i.e. meet Federal guidelines for severity of illness and intensity of service), we do not desire to be in a position where our actions, even when done for the best interests of the patient, could be considered as circumventing Federal regulations. That could lead to very serious repercussions.

At Newton-Wellesley Hospital (NWH), we have been engaged for the last several years in an educational effort trying to assure our patients’ admissions meet the medical necessity guidelines. Both because of the not infrequent lack of clarity of the medical necessity guidelines (Interqual criteria are used) and the often complex conditions of our patients, this process has been complicated and has necessitated enhanced physician education, CPOE refinements, and staffing changes. The Care Coordination department has the responsibility to review every admission for medical necessity, to support the admitting physicians in their decision making process, and oftentimes talk with the family about the level of care (Inpatient or Observation) to which the patient is admitted. In this role, Case Managers may be put in the uncomfortable position of contradicting the expectations that the physician set about the hospitalization. “Observation” cases do not meet Federal guidelines for inpatient care.

From a compliance standpoint, it is important to follow the Medicare regulations and to assure that every admission is based purely on the medical necessity of the case at the time of the admitting physician’s decision. NWH can never admit a patient for an inpatient stay simply as a means to meet the post-acute facility three-day inpatient stay qualification. In today’s highly regulated environment, that could be considered a serious punishable legal offense with profound consequences.

Prior to recommending hospital admission for a patient at home about whom you are not sure if they will meet inpatient qualifying criteria, we suggest you call 617-243-6695, which is the number for the Hospital’s Care Coordination Unit. In the future, you will also be able to call the Bed Control service. However, when the patient is acutely ill, they should be sent to the hospital first, and we can discuss later.

Thank you.

From Leslie G. Selbovitz, MD, Chief Medical Officer and Leslie Chun, MD, Director, Health Care Quality