You can read all the time about the payment models and the ups and downs of it and the re-admissions penalties are right up there.  I would think by now CMS would have some better modeling in place than what comes down the tubes as when we see all the hospitals caring for the poor getting fined, what’s wrong with that picture?  To me it states that in order to be fair and try and compare apples imageand oranges someone needs to update their segmentation parameters as they don’t play out very well most of the time.  For Obamacare some hospitals have even created their own insurance plans and some will be in the insurance exchanges, so they don’t hate everything.

I went through some of this personally with my mother before she passed on about the “admittance” rules and what we had to do with running her admittance through the ER room as she needed surgery and actually was under observation until after her surgery took place, (I watched the paper flow and was there) and the rest of the time she was under observation, so a normal admittance was not possible to ensure Medicare coverage without some algorithm kicking it out. 

She had  part D plan and I’ll tell you it was interesting to watch the doctors adhere and knew each procedure so there would not be something billed that was supposed to be covered with an unmatched single parameter.  It’s amazing to see how the doctors and all have learned how to manipulate patients through all of this instead of just being admitted through the front door of the hospital like normal admissions go.  I was happy they were up to snuff as it saved me a lot of potential aggravation later with billing.  They end up paying what they are supposed to pay but the extra gyrations patient go through to get there is not really needed to me from what I saw. 

Medicare Admissions Rules Causing Havoc, Need a New Model As It Is Becoming Yet One More Way to Shift Cost to the Patients

Now hospitals are looking at the 2 midnight rule to where patients who stay less than that will be subject to a payment algorithm that says it should have been outpatient treatment.  Well golly gee we have hospitals that have both regular surgery rooms and out patient surgery rooms, right next door or in the same facility.  They look identical but this extra expense of building two sets helps keep the nightmares of the auditors away.  It didn’t take me long to figure that one out:)  We end up with this cat and mouse billing game here.  Like I wrote before not much different than flipping a coin as an auditor can dig into any complex hospital bill and find something if they want. 

Readmission Analytics Not Much Better Than Flipping A Coin, Large and Poorest Hospitals At Risk Of Facing Larger Fines, CMS Needs Some New Math Models and Algorithms

So now hospitals get a 90 delay for the auditors run out and pounce on the less than 2 midnight stays.  These are contracted auditors that go out and count beans and dig and I am guessing their analytics will tell the contractors what cases to look at before they go out. 

One algorithms with said parameters does not fit all but that is what CMS plans to continue? 

Gov can’t or won’t model?

We already know the head of HHS is Algo Duped half  the time with apps and some of the other nonsense numbers that come out of there and they are said imagepublicly in the press (like hospitals and doctors are all liars on their billing for one) so it would stand to reason that this same paradigm runs through the entire agency, except for the FDA, much smarter over there thank goodness and they have other issues but not this one as they have to model and valuate P values an much more with drugs and devices so they are much more in tune.  Scroll down and watch the first video in the footer and see what I mean about context and it will make sense what I said about Algo Duping and sucking in marketing and data that isn’t so. 

“Dead Patients Can’t Be Readmitted” As Relates to HHS and CMS and the Elusive Search for Some Penalty Assessing Algorithm Fairies…

I realize there are standards and guidelines that have to be met but the modeling over at CMS is way too simple, get some lessons from insurers who hire batteries of Quants to model by the minute on every penny or at least get closer as the simple model is making everybody mad as it doesn’t apply equally as what CMS is trying to do.  Hospitals and doctors are waking up to this fact as they have been duped with complex insurance contracts and end up being paid less than Medicare too. 

The reasoning sounded a bit crazy to me that this was to increase hospital payments by allowing more time to become eligible for inpatient rates…why not just let a patient be eligible for inpatient care when it’s needed, don’t doctors determine that?   I don’t know anyone who “want” to be an inpatient today if they don’t have to…so we go around and around..with the parameters of an inpatient and the auditing to make sure those numbers are met..bad enough the re-admission penalties are out there as well as poorly modeled too.  So this is what bugs hospitals right now and there maybe more of course but these the are big ones with money and time and software right now. 

We already have several flavors of re-admission software so what subsidiary of an insurance company is going to introduce admission software that will calculate all the parameters here and increase the complexities of the rule?  (grin).  BD 

Addressing widespread anger among hospitals and doctors about the new “two-midnights” rule for outpatient observation, CMS officials announced Thursday that government recovery auditors will delay scrutiny of short inpatient stays for 90 days while providers get acclimated to the new policy.
This week 100 members of Congress signed a letter asking the CMS to postpone the rule so that federal officials could listen to more feedback and change it. The CMS is not doing that.

“What CMS is looking for here is for the provider community to get their education and training done on the rule as written, but without the burden of worrying about what a RAC contractor might or might not do,” said Emily Evans, partner with Obsidian Research Group. “So they are taking some of the financial pressures off the providers while they learn how to comply with the rule.”

The two-midnights rule says that hospital stays that last two days—defined as a stay that spans at least two midnights—are presumed to be legitimate uses of inpatient care and will not be subject to auditing, for the most part. Likewise, most stays that are shorter than that are presumed to have been appropriate for outpatient observation, a level of care for which Medicare pays less and subjects patients to much higher costs.


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