Following the END of the #COVID19 PANDEMIC, it will likely take months if not years to untangle the mess caused by the fast and furious implementation of changes and waivers to the #UtilizationManagement (UM) process.
Expect that Payers and Providers will have disagreements about the interpretation of these waivers. ENSURING REIMBURSEMENT of MEDICALLY NECESSARY SERVICES, will be CRITICAL to the FINANCIAL STABILITY of MANY HOSPITALS.
Payers too, will look to minimize losses, especially with projected declines in member enrollment, and increased payment for medically complex patients who require a prolonged period of recovery.
While it is difficult to keep in the forefront of our thoughts, it’s still important for Physician Advisors and UM services to IMPLEMENT STRATEGIES NOW to DECREASE the IMPACT later.
Utilize the following release for considerations to take into account at your organization.
CONSIDERATIONS
- When it does not compromise patient safety, or the performance of the system, FOLLOW THE STANDARD RULES AND REGULATIONS. In other words, just because there is a waiver does not necessarily mean you must use it.
- CLEARLY DOCUMENT at the time of service, when EXTERNAL FORCES have ALTERED the NORMAL PROCESS. E.g. a lack of payer authorization for hospitalization, due to either the payer’s inability to review the case, or the urgency of medical care within the facility.
- DOCUMENT CLEARLY when there is a NEED for CONTINUED HOSPITALIZATION of a STABILIZED (but still infectious) PATIENT, DUE to a COMMUNITY BENEFIT. E.g. a danger to the community due to potential spread of a communicable disease.
- ENSURE INSTITUTIONAL MEMORY regarding the TIMEFRAME RELATED to the EMERGENCY DECLARATION and ASSOCIATED CMS/PAYER WAIVERS. Any retrospective denials between 13 MARCH, 2020 (the date the Stafford-based declaration of a national emergency was announced), and the yet to be determined end date of the emergency, should be based upon the rules and regulations in place to manage services during the COVID19 Pandemic.