Hospital EDs Seeing Sicker Medicare Patients

John Commins, for HealthLeaders Media , May 8, 2013

"We would just like recognition by [the Centers for Medicare & Medicaid Services] that patients are in fact getting sicker and that it is not related to changes in the coding claims, but that we really are seeing patients getting sicker," she says. "We have run into this problem in the inpatient setting as well, where CMS doesn't want to pay for rising acuity levels."  

The federal government's more stringent inpatient admissions guidelines and growing claims denials are also putting more pressure on hospitals to treat Medicare patients in the ED rather than admit them.

"We are seeing an increase by audits by the [recovery audit contractors] and other Medicare auditors that are denying admission for short stays so there is huge pressure on hospitals not to admit patients unless they are very sure that those cases can be fully justified through medical necessity," Steinberg says.

"Nobody is questioning whether the care provided was medically necessary. They are just questioning whether or not it was provided in the right setting."

CMS in March said it would change its policy of flatly denying any reimbursements to hospitals that provide medically necessary care determined by auditors to have been delivered inappropriately in an inpatient setting. While that will allow hospitals to re-bill Medicare for hundreds of millions of dollars in uncompensated care, Steinberg says re-billings can only date back one calendar year.

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