Knowledge Base Article

As a new Hospital Case Manager in the 1990’s, I performed the job duties that I was taught in orientation but often wondered why we did some of the things that we did. Why did we have a quarterly Utilization Review Committee meeting? Why did we give our patients a patient choice list of Home Health Agencies, Skilled Nursing Facilities and Hospice Agencies? What I have learned and continue to learn is that there is a lot more to Case Management and Discharge Planning than “looking at charts” all day and to be compliant you need to understand the “why” of what you do as much as the “how you do it.”

CMS has indicated that the CoPs “health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries.”

The Social Security Act (the Act) Sections 1861(e)(1) through (8) indicates that hospitals that participate in the Medicare program must meet specific requirements. Section 1861(e)(9) of the Act further specifies that “a hospital must meet such other requirements as the Secretary finds necessary in the interest of the health and safety of individuals furnished services in the institution.” (Federal Register / Vol. 76, No. 205 / Monday, October 24, 2011 / Proposed Rules / page 65892)

This is where the Conditions of Participation (CoP) enter into the “why” of it. CoPs for health care organizations, simply put, are the guidance that must be met to be able to start and continue to participate in the Medicare and Medicaid programs. According to the Centers for Medicare and Medicaid Services (CMS) “these health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries.” (https://www.cms.gov/CFCsAndCoPs)

Hospital CoPs can be found in the Electronic Code of Federal Regulations under Title 42: Public Health, Part 482 – Conditions of Participation for Hospitals. “The CoPs are organized according to the types of services a hospital may offer, and include specific, process oriented requirements for each hospital service or department. The purposes of these conditions are to protect patient health and safety and to ensure that quality care is furnished to all patients in Medicare-participating hospitals.” (Federal Register / Vol. 76, No. 205 / Monday, October 24, 2011 / Proposed Rules / page 65892)

Section 1864 of the Act indicates that State Surveyors assess the compliance of facilities to determine whether or not they qualify to participate in the Medicare program. Per Section 1865 of the Act, “hospitals can elect to be reviewed instead by private accreditation organizations approved by CMS as having standards and survey procedures that are at least equivalent to those used by CMS and State surveyors.” (Federal Register / Vol. 76, No. 205 / Monday, October 24, 2011 / Proposed Rules / page 65892) In December of 2011, CMS updated the Approved Accreditation Organization Contact Information. The Joint Commission is an approved Accreditation Organization.

The three Hospital CoPs that Case Managers and Discharge Planners should become familiar with. These CoPs are:

• §482.13 Condition of Participation: Patient’s rights,
• §482.30 Condition of Participation: Utilization Review; and
• §482.43 Condition of Participation: Discharge Planning.

Understanding these specific CoPs will lay the groundwork for Case Managers and Discharge Planners in understanding the “why” of the duties they perform in their job every day.

§482.13 Condition of Participation: Patient’s rights

Standard §482.13(a)(1) “A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible.”

“In part as a result of the Weichardt v Leavitt lawsuit, CMS published final regulations on November 27, 2006, that established revised requirements for how hospitals must notify Medicare beneficiaries who are hospital inpatients about their discharge appeal rights.”

Embedded within the guidance of this standard are details regarding providing Medicare Beneficiaries with the standardized notice, “An Important Message from Medicare” (IM). Case Management and Discharge Planning became involved in this process on July 2, 2007 when participating hospitals were required to begin not only providing an IM to Beneficiaries on Admission but to provide a second IM prior to but not more than two days before discharge.

CMS provided Questions and Answers on April 3, 2007 related to this new process. One of the Q&A’s explained how in part this new process was the result of a lawsuit. The IM form advises Beneficiaries about their Medicare Discharge Rights and that hospital staff will work with them to plan for a safe discharge, arranging for any post-acute care services that they may need. The IM also advises the Beneficiary that when they no longer need inpatient services that the doctor or hospital staff will make them aware of a planned discharge date.

In 2009 the American Case Management Society (ACMA) Public Policy Committee surveyed Case Management Professionals about their experience with providing the IM second notice. L. Greg Cunningham, ACMA CEO, shared the responses with a group of CMS administrators at the agency headquarters in Baltimore. Following this meeting, CMS requested that the ACMA submit a prioritized list of issues and concerns regarding the IM second notice. The outcome of this proactive endeavor by ACMA was that CMS provided FAQ Documentation Addressing Case Managers Concerns and that the current IM form was modified to include a place to time when the form was signed. This updated form went into effect on April 1, 2011.

§482.30 Condition of Participation: Utilization Review (for Medicare Beneficiaries)

“The hospital must have in effect a utilization review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid program.”

Utilization Review requirements for Medicare and Medicaid

§482.30 Condition of Participation: Utilization Review (for Medicare Beneficiaries) “The hospital must have in effect a utilization review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid program.”

The State Operations Manual - Appendix A, Interpretive Guidelines for §482.30 indicate that “the Utilization Review CoP is not a part of the deemed program for hospitals, per 42 CFR 488.5. As such, State Survey Agencies have jurisdiction over the UR CoP for accredited and non-accredited hospitals.”

Specific Standards within this CoP are: the Composition of the UR Committee, the Scope and Frequency of Reviews, determination regarding admissions or continued stays, extended stay reviews and the review of professional services.

Survey Procedures for evaluating the Standards include:

• Determine that a hospital has a UR Plan for services provided to Medicare and Medicaid patients by a hospital and its medical staff.
• Verify that UR activities are being performed as outlined in the Hospital’s UR Plan.
• Review UR Committee meeting minutes to verify that they include dates, members present, extended stay reviews with approval or disapproval noted and a report of any actions taken.
• Determine the composition of the UR Committee.
• The Committee must have at a minimum 2 Doctors or Medicine or Osteopathy.
• Determine that the UR Committee has received authority and responsibility to carry out its function by the hospital’s governing body.
• For small hospitals where it is not practical to have a staff committee, verify that the hospital delegated the UR function to an outside group.
• Verify that UR Committee members do not have ownership of 5 percent or greater in the hospital and were not involved in the planning or carrying out of the patient’s treatment plan.
• Review the UR Plan and other documents to confirm that medical necessity is reviewed for admissions, continued stays and professional services furnished.
• For Inpatient Prospective Payment System (IPPS) Hospitals verify that outlier cases and professional services in outlier cases are reviewed.

Title 42 – Public Health - Part 456 – Utilization Control - Subpart C – Utilization Control: Hospitals (for Medicaid Recipients)

A key standard within this section is that hospitals need to be aware of is the Medical Care Evaluation Studies as detailed in §456.141 - §456.145. “The purpose of medical care evaluation studies is to promote the most effective and efficient use of available health facilities and services consistent with patient needs and professionally recognized standards of health care.”

Hospitals must at a minimum have one Medical Care Evaluation study in progress at any time and complete one study each calendar year. §456.145

§456.143 details what must occur in a Medical Care Evaluation Study and includes:

• Identify and analyze medical or administrative factors related to the hospital’s patient care;
• In the analysis the minimum to be included are: Admissions, Durations of Stay, Ancillary services furnished (including drugs and biological, Professional services performed in the hospital and if indicated should contain recommendations for changes beneficial to the patient, hospital staff, hospital and the community.

§482.43 Condition of Participation: Discharge Planning

Interpretive Guidelines in the State Operations Manual – Appendix A, indicate that “this CoP applies to all types of hospitals and requires all hospitals to conduct appropriate discharge planning activities for all inpatients.” The Guidelines go on to indicate that “adequate discharge planning is essential to the health and safety of all patients. Patients may suffer health consequences upon discharge without benefit of appropriate planning. Such planning is vital to mapping a course of treatment aimed at minimizing the likelihood of having any patient rehospitalized for reasons that could have been prevented.”

With the 30 Day Readmission Reduction Program set to begin October 1, 2012, Discharge Planning is more important than ever and is a first step to providing smooth transitions of care for our patients. A good evaluation begins with assessing a patient’s functional status, their cognitive ability and their family support.

“The Hospital must inform the patient or family as to their freedom to choose among providers of post-hospital care.”

- Interpretive Guideline of §482.43(b)(4)

This CoP answers the question of why we provide patient choice lists for Home Health Agencies (HHA), Skilled Nursing Facilities (SNF) and Hospice agencies.

The State Operations Manual – Appendix A - Interpretive Guidelines expectation is that hospitals “provide a list of Hospice, HHAs or SNFs that are available to the patient, that participate in the Medicare program, and that serve the geographic area that the patient requests.” The expectation is that the hospital will document in the medical record that a list had been provided to the patient or the person acting on the patient’s behalf. Hospitals have been allowed the flexibility to develop and maintain their own lists. It is important to note that hospitals are prohibited from steering patients to a particular agency and must disclose when the hospital has a financial interest in the agency.

The Conditions of Participation provide guidance for Hospitals that participate in the Medicare and Medicaid programs. There are three specific CoPs that provide an answer to why Case Managers and Discharge Planners provide the second Important Message from Medicare to Beneficiaries, why you have a Utilization Review Plan and Committee Meetings and why you provide discharge planning for all patients in the inpatient setting. More importantly, these CoPs support the ACMAs definition of Case Management in that “Case Management in Hospital/Health Care Systems is a collaborative practice model including patients, nurses, social workers, physicians, other practitioners, caregivers and the community. The Case Management Process encompasses communication and facilitates care along the continuum through effective resource coordination. The goals of Case Management include the achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patient’s right to self determination.”

References

The Federal Register / Vol. 76, No. 205 / Monday, October 24, 2011 / Proposed Rules / page 65892. Retrieved March 29, 2012, from http://www.gpo.gov/fdsys/pkg/FR-2011-10-24/pdf/2011-27175.pdf

CMS webpage overview of the Conditions of Participation (CoPs) Retrieved March 29, 2012 from https://www.cms.gov/CFCsAndCoPs

Electronic Code of Federal Regulations Retrieved March 29, 2012 from http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=%2Findex.tpl

CMS-Approved Accredited Organization Contact Information Retrieved March 29, 2012 from https://www.cms.gov/SurveyCertificationGenInfo/Downloads/AOContactInformation.pdf

Final Rule: Notification of Hospital Discharge Appeal Rights (CMS-4105-F) Qs AND As (April 3, 2007) Retrieved March 29, 2012 from https://www.cms.gov/BNI/Downloads/CMS4105FINALRULEQsandAs2007.pdf

CMS Provides ACMA with FAQ Document Addressing Case Managers’ Concerns Surrounding the IM Second Notice Retrieved March 29, 2012 from http://www.acmaweb.org/forms/IM_FAQ.pdf

State Operations Manual – Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev. 81,03-23-12) Retrieved March 29, 2012 from http://www.cms.gov/manuals/Downloads/som107ap_a_hospitals.pdf

American Case Management Society of America (ACMA) definition of Case Management Retrieved March 29, 2012 from http://www.acmaweb.org/section.asp?sID=4&mn=mn1&sn=sn1&wpg=mh