Wednesday, March 9, 2011

CMS addresses inpatient admission decisions (common source of fraud)

Qui tam lawyers and AUSAs know that one of the most difficult health care fraud cases to prove is unnecessary or excessive care.  The provider defends himself with arguments such as it's best for the patient or I'll be sued if I don't do procedures X, Y, & Z.   The CMS Center for Program Integrity issued a news flash to address the issue of inpatient admin decisions (which in some of my investigations, is an easy way to commit health care fraud.)

Basically, CMS is telling industry that a  patient's convenience or personal needs should not factor into a decision to admit him for an inpatient stay.  Continuing a patient's hospitalization must hinge on the safe delivery of the patient's care and on whether the patient's health or safety would suffer if the care were provided in a less intensive setting, CMS says in its updated "Guidance on Hospital Inpatient Admission Decisions." It's also part of new guidance CMS issued this week to try to deflect hospital concerns that its contractors are using analytic software to screen for cases they can deny. CMS admits its contractors do use screening tools, such as those from Interqual, Milliman and other vendors, to identify cases that may not qualify as medically necessary.


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