Discussion w15-16 652

Q-1

Provide one detailed example of each scenario listed and explain the regulatory language surrounding the action.

 

1. An appropriate inpatient admission for Medicare.

An appropriate medicare inpatient admission would consist of several criteria such as the patient needing to stay at least three midnights in the hospital in order to receive appropriate care (Observation or Inpatient, N.D.). You also need a physician's order that states that you need to be admitted and hospitalized for at least three midnights meeting the criteria (Observation or Inpatient, N.D.). An example would be a patient who comes in with chest pain and has a positive troponin along with it. In this scenario, there is medical criteria that indicates the patient needs hospital care, and possible subsequent cardiac-related procedures that could take up to three midnights (Observation or Inpatient, N.D.). The provider now has the criteria necessary to certify the need for inpatient admission, and would then have to write the order (Observation or Inpatient, N.D.).

 

1. An appropriate outpatient admission for Medicare.

An appropriate outpatient admission would be services rendered in an emergency room or acute care facility, while receiving surgical procedures, tests, and diagnostic studies whose results do not warrant inpatient admission due to the expected stay being less than 72 hours (Inpatient or Outpatient Hospital Status Affects your Cost, N.D.). An example would be if a patient came in for an elective vocal cord biopsy, and post procedure the patient developed symptomatic bradycardia, there would be cardiac workups and diagnostics that could be completed in a timely fashion less than 72 hours (Inpatient or Outpatient Hospital Status Affects your Cost, N.D.). This would be considered to be an outpatient admission or observation admission (Inpatient or Outpatient Hospital Status Affects your Cost, N.D.). It is also possible that if there were subsequent positive findings that the patient could be changed from outpatient to inpatient if the criteria are met due to the patient staying in the hospital longer than 72 hours to receive appropriate care (Inpatient or Outpatient Hospital Status Affects your Cost, N.D.).

 

1. An example of an appropriate Medicare-patient appeal for a delay in discharge.

Once an appeal is filed, an independent reviewer will look over the case and decide if the stay needs to be extended (Getting A Fast Appeal in the Hospital, N.D.). If a patient files an appeal, with good reason, there could be an extension stay applied to the patient (Getting A Fast Appeal in the Hospital, N.D.). An example would be if a patient was admitted to the hospital with an infected leg, received antibiotics, and a culture was taken. If this culture came back with a powerful bacterial infection that was resistant to antibiotics, and the patient was concerned that they were not receiving the appropriate antibiotics they could file an appeal. During this appeal process, the reviewer could find that the culture showed sensitivity to the antibiotic and that the patient would need IV antibiotics with appropriate hospital services, of appropriate coverage during an inpatient stay, they could extend the patient's stay and overturn the physician's original discharge order (Getting A Fast Appeal in the Hospital, N.D.).

References:

Getting A Fast Appeal in the Hospital. (N.D.). Claims and Appeals. Medicare.Gov. Retrieved from:  http://medicare.gov/claims-appeals/your-right-to-a-fast-appeal/getting-a-fast-appeal-in-a-hospital

Observation or Inpatient? (N.D.) Medicare Patients. Health Quality Institute. Retrieved from:  https://www.mgh.org/Content/Uploads/UP%20Health%20System%20-%20Marquette/files/Assigning%20Appropriate%20Patient%20Admission%20Status.pdf

Inpatient or Outpatient Hospital Status Affects your Cost. (N.D.) What Medicare Covers. Medicare.gov. Retrieved from:  https://www.medicare.gov/what-medicare-covers/what-part-a-covers/inpatient-or-outpatient-hospital-status

Q-2

Appropriate inpatient admission for Medicare.

A 70-year-old female patient present to the emergency dept with sepsis secondary to community-acquired pneumonia. The patient requires supplementary oxygen and is started on intravenous antibiotics. The admitting provider expects that she will need more than 2 nights of hospital care and suggests inpatient status, rather than outpatient (observation) status, would be appropriate under Medicare’s two-midnight rule. The physician also suspects that patient may need a brief stay in a skilled nursing facility following the hospitalization and notes that the patient has a Medicare Advantage plan which may cover three-midnight rules for SNF benefits in discharge planning (Kaiksow et al, 2020).

An appropriate outpatient admission for Medicare

The patient must be hospitalized for three consecutive inpatient midnights to qualify for the SNF benefits (Kaiksow et al, 2020). An obese patient who had hip replacement surgery spent 3 days in the hospital. Documentation of patient’s progress and mobility, and the interventions completed daily all needed to be documented. This patient requires rehabilitation by PT and OT therapy in SNF post-discharge for mobilization and to improve the performance in meeting patients' activities of daily living. The SNF stay is to be covered by Medicare.

An example of an appropriate Medicare-patient appeal for a delay in discharge.

A perfect example of this scenario was the patient had bowel surgery, end up having post-op complications of the ileus, and required to stay in the hospital for a week. The patient has been mobilized the day of surgery and properly provided respiratory care including deep breathing, coughing, and incentive spirometry post-operatively which will reduce post-operative complications. This delay in hospitalization may be justified because of the expected possible complications of the bowel surgery post-operative ileus and not due to any delay or negligent care before, during, or after the surgery. This patient's hospital stay can be appealed for an extended stay until acute complications are resolved. Proper assessment and documentation are necessary to justify the reason for an extended hospital stay.

Reference.

Kaiksow, F. A., Powell, W. R., Ankuda, C. K., Kind, A. J., Jaffery, J. B., Locke, C. F., & Sheehy, A. M. (2020). Policy in Clinical Practice: Medicare Advantage and Observation Hospitalizations. Journal of hospital medicine, 15(1), 6-8. Retrieved from https://www.journalofhospitalmedicine.com/jhospmed/article/214485/hospital-medicine/policy-clinical-practice-medicare-advantage-and

Q-3

Using the Emergency Medical Treatment and Labor Act (EMTALA) as a resource, provide one example of a safe and legal emergency department transfer/discharge and one example of a concerning and potentially illegal emergency department transfer. Explain, in detail, each of the two situations and the safety and legal implications of these health care transitions for both the patient and the facility or facilities involved. There are many stipulations and requirements under EMTALA in order to safely transfer or discharge a patient from the ER to home or to another floor, respectively (Lulla & Svancarek, 2020). Patients who arrive with a chief complaint need to be assessed and evaluated by a medical physician or qualified medical professional and assessed with an appropriate medical screening (Lulla & Svancarek, 2020). This will allow the physician or medical professional to effectively evaluate the patient as either needing emergency services or not (Lulla & Svancarek, 2020). Patients who have an emergency medical condition have to be stabilized as best as their facility can provide (Lulla & Svancarek, 2020).

Within these basic parameters, an appropriate discharge would be one of a patient who has come in with chest pain, received a complete cardiac workup including EKG, ECHO, and Cardiac enzymes, and was then subsequently admitted to the cardiac floor for observation (Lulla & Svancarek, 2020). This would include a patient with a chief complaint, then being evaluated by a medical physician or medical professional with an appropriate medical screening, and it was determined that it was significant enough to require hospital admission for observation (Lulla & Svancarek, 2020).

Using these parameters from EMTALA, an example of an illegal or unsafe discharge was found in the case study, Civil monetary Penalties Resulting from Violations of the Emergency Medical Treatment and Labor Act, where it was found that violations such as failure to provide appropriate medical screening, failure to arrange an appropriate transfer, and failure for an on-call provider to respond were occurrences when involved with a patient ( Wang et al., 2019).

One example was that a patient had come in with a psychiatric emergency and the provider did not provide a psychiatric exam, but only a physical exam, and readily consulted psych without the appropriate documentation (Wang et al., 2019). Subsequently, the provider then readied transport to a psych facility without first stabilizing the patient's emergency psychiatric condition (Wang et al., 2019). These violations were found during the case study and constitutes an EMTALA violation and an unsafe transfer (Wang et al., 2019).

References: Lulla, A., Svancarek, B. (2020). EMS USA Emergency Medical Treatment and Active Labor Act. StatPearls Treasure Island StatPearls Publishing. Retrieved from:  https://www.ncbi.nlm.nih.gov/books/NBK539798/ Wang, B., Burner, E., Connor, D., Seabury, S., Menchine, M. (2019). Civil Monetary Penalties Resulting from Violations of the Emergency Medical Treatment and Labor Act (EMTALA) Involving Psychiatric Emergencies, 2002 to 2018. Academic Emergency medicine. Retrieved from:  https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13710