SDW news brief: CMS issues guidance on hospital inpatient admissions

Staff Development Weekly: Insight on Evidence-Based Practice in Education, January 28, 2011

Medical necessity determinations are not just a hot button issue with Recovery Audit Contractors (RAC), but also with the other 'usual suspect' government auditors: Medicare administrative contractors (MACs), fiscal intermediaries (FIs), and comprehensive error rate testing (CERT) contractors. So much, in fact, that the Centers for Medicare & Medicaid Services (CMS) has released educational guidance to assist hospitals regarding inpatient admission decisions.

While many hospitals may be utilizing proper screening criteria to analyze documentation and make medical necessity determinations, the fact remains that it's an imperfect endeavor. And while Interqual and Milliman, as well as other additional systems, may assist facilities in specific jurisdictions, CMS has issued a special edition MLN Matters article that points providers toward its own manuals for guidance.

In the Program Integrity Manual, CMS states that contractor review staff are required to use a screening tool as part of their medical review process for inpatient claims, but it does not require that the contractor use specific criteria nor endorse any particular brand of guidelines. In addition, "CMS contractors are not required to pay a claim even if screening criteria indicate inpatient admission is appropriate. Conversely, CMS contractors are not required to automatically deny a claim that does not meet admission guidelines of a screening tool."

To read the rest of the free article, click here.

Source: HealthLeaders Media

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