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COVID-19 Commercial Readmission Denials Nicholas S. Libertin, MD If your health system has not received commercial COVID 19 related readmission denials...they will soon. At the inception of the pandemic, my health system did not receive ANY of these denials for our COVID 19 patients. Then…they slowly began to trickle in. They may be disguised as COPD or CHF exacerbations who “just happen” to be COVID +, have bibasilar infiltrates on CXR, acute hypoxic respiratory failure, a cough and lymphopenia…but there they were. Commercial insurance providers will deny a second inpatient stay if they feel it is directly related to the 1st admission and within 30 days. Different insurers have different exceptions to this policy (oncologic care, AMA etc.) but the overarching theme is the same. COVID 19 presented a plethora of challenges for health systems that were dealt with in real-time. Do we treat with Remedesivir and steroids? Who do we treat? Who needs to be admitted to the hospital? Who can safely go home? We quickly discovered elderly patients as well as those with major comorbidities were at higher risk for adverse outcomes. Hospitals and communities banded together and began evolving care at a rapid rate. Patients' hospital length of stay decreased as more aggressive outpatient treatment regimens were developed to save hospital bed space for the critically ill. These same insurers even started to argue that many of our hospitalized patients could have care rendered elsewhere. COVID has proven itself unpredictable, and unfortunately a subset of patients will decompensate as part of the natural progression of the disease and subsequent complications. Patients can suddenly deteriorate weeks after their positive PCR test and symptom onset due to a cytokine storm. It is not feasible to monitor these patients in a hospital bed simply for the possibility that they will deteriorate and be readmitted (for 30 days no less!). This would unnecessarily occupy bed space (not ideal for insurers nor hospitals) and place other hospital patients at risk. The hospital is thus put in an impossible dilemma. As advocates for both our patients and health systems, we need to be proactive in fighting these readmission denials. These admissions are not preventable nor avoidable (especially given the resources at the time), and the health system should not be penalized for providing excellent care. The first and most important step is documentation education. In our health system we have monthly educational sessions that are provided by physician advisors specific to each facet of our health system (outpatient, inpatient and emergency room). We also have physician documentation specialists to help our providers capture acuity. Once the readmission denial has been administered, we make sure to appeal nearly all of these with a letter written by one of our physician advisors. I have had some success in overturning these denials by providing well established data in my appeal letters. I will include the patient’s COVID-GRAM Critical Illness Risk Score and Veterans Health Administration COVID-19 (VACO) Index for COVID-19 Mortality (both easily calculated on the website “MD Calc”). These provide objective assessments of a patient’s risk for critical illness and mortality. Now, if only we could develop a score that predicted the likelihood of insurance companies retroactively denying inpatient admissions during the midst of a pandemic? Does the patient have a beating heart? Each affirmative answer scores a 1 and any score of 1 or more is subject to denial (Shout out to Dr. Carolyn Dutton for this scoring system) References:
Dr. Libertin became a Cleveland Clinic Enterprise Physician Advisor in 2020 and is ABQAURP Health Care Quality and Management Certified with a physician advisor sub-specialization. He is a Clinical Assistant Professor of Emergency Medicine at Case Western Reserve University. |