COVID-19 Case Management and Utilization Management FAQ’s
On March 27, Xsolis hosted a roundtable discussion with five utilization review leaders who answered attendee questions and shared their own thoughts on how UR leaders should plan and adapt to this crisis. The following edited transcript contains answers from the panel, which included:
- Michelle Wyatt, DNP, MSN, RN, IQCI, CPHM Director of Clinical Best Practice at Xsolis
- Heather Bassett, M.D. Chief Medical Officer at Xsolis
- Robin D. Bryant, LPN Clinical Application Trainer at Xsolis
- Brandon Halas, BS, RN, CCM Clinical Application Trainer at Xsolis
- Patty Dietz, BSN, RN, CPHQ, ACM-RN Clinical Sales Director at Xsolis
Q: With the influx of patients, how is the downstream workload of UR nurses and Case Managers being affected? What do you see as the long-term effects?
A: Overall census may be down in some areas with the postponement of elective surgeries. However, in many areas, an influx of very sick patients has taken place. As a result, case managers may see, or are already seeing, an increased workload. Because these patients are very sick, they are likely going to be classified as inpatient. But also with this increase comes throughput challenges and possible staffing shifts which could include moving nurses to areas such as triage, telehealth, follow-up, etc.
Regarding long-term effects, staff may have to re-prioritize their work based on what patients require their most immediate attention at the beginning of the day. As leaders, we need to provide staff with the skills, confidence and technology that are essential for staff to get through this unusual time. Cross-coverage may not be allowed depending on lockdown areas within the hospital. Further, some hospitals are pulling out UR teams and having them work remotely.
Q: Some hospitals are so short-staffed that they are pulling nurses from UR/CM back on the hospital floors that need them. What can UR managers do to accommodate this? Will the future of UR be remote?
A: Nurses that were most recently on the floor should be pulled as their skills are most finely tuned. Also, only nurses that are outside of the high-risk group should be re-assigned to these other areas that are trying to accommodate overflow. Nurses that have underlying conditions or are immune-compromised should work from home, if possible. In terms of the future of UR, it is important to have flexibility. We must learn to adapt even if staff are being asked to work remotely despite many not being set up as a centralized system. This requires healthcare workers to step outside of their comfort zone in some cases, but with manageable modifications, they can still be just as, or more, productive than in a hospital setting.
Some added benefits to working remotely include the ability to often reach health plans early and ensure your calls make it through. Additionally, transportation issues or commuting delays are no longer affecting productivity. However, some remote workers may experience bandwidth or internet service hurdles. Stay in close communication with your IT associates to minimize those kinds of issues or address them quickly. Also, many are having trouble connecting with their physicians. To help solve this problem, many states have offered free Zoom licenses to assist healthcare workers with colleague and physician connectivity, and boost productivity. As a reminder, CORTEX is a web-based application, which allows easy access from home and for one client, it has been the UR team’s only access to clinical information due to to bandwidth issues in remotely accessing the EMR.
Q: Given the guidance from CMS on COVID-19 cases, what do you see changing?*
A: CMS issued a blanket waiver for Skilled Nursing Facilities (SNFs) • Waives 3-day Inpatient admission requirement for Part A SNF benefits • Patient still requires a skilled need • Waiver covers beneficiaries who recently exhausted SNF benefits • PASRR for SNF admissions requires state by state waiver • Medicare advantage plans have separate flexibilities and may choose to waive prior authorization requirements. • On March 24th, United Healthcare suspended prior authorization requirements for post-acute care settings through May 31st and may update this guidance for April.
Of the guidelines listed above, acute inpatient consults are of interest. A blanket waiver was issued from CMS for skilled nursing facilities, eliminating the standard of 3 inpatient days required for a SNF stay. However, the patient still must demonstrate a need to go to a skilled nursing facility. Also, of interest is that the waiver covers nurses who may have lost their skilled nursing days, which indicates you don’t have to wait until that has re-set or has been re-established.
CMS telehealth waiver during COVID-19 public health emergency:
- Includes telehealth services provided in any healthcare facility or in the beneficiary’s home that generally occur in-person
- Requires inactive audio/video telecommunication system that permits real-time communication which can include FaceTime or Skype (HIPAA waiver also in place).
Stay current with CMS’ website to see updated guidelines and waivers. Once the state of emergency has been lifted, it will be important to look to CMS to see what guidelines remain in place and the timelines for change.
Lastly, because all hospitals are low on PPE, we must be resourceful. Make sure PCPs and practitioners are aware of these guidelines regarding telehealth and the waiver of HIPAA requirements to manage patient flow and follow up. This is an ever-changing environment, so consider referencing online resources to keep up with current information.
*Editor’s note: guidance from CMS and other entities is constantly evolving as the situation changes. Find the most up to date information from CMS, visit their current emergencies page: https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page
Q: How is the response shaping up on the payer side? What can providers do to help streamline processing and authorizations?
A: Payers are still sending some denials for inpatient if the patient doesn’t meet their severity of illness requirements for inpatient level of care, even if they have a diagnosis of COVID-19. They must have severe symptoms or co-morbidities. Streamlining concurrent reviews may not be necessary, but staff need to keep managing length of stay, now more than ever. We recommend having open dialogue with your payers as much as possible. Continue to focus on the high-risk patients with co-morbidities or who are immunosuppressed.
The two-midnight rule is still in effect. That said, consider things like if a negative pressure isolation room is required for the patient.
Q: Did we see any issues from a HIPAA standpoint in providing COVID-19 results to payers?
A: No. This is because it is viewed (and should be viewed) like any other test result given in the hospital.
Q: What is your suggestion to deliver IMM in timely manner if the patient is in isolation? Their staff nurses will not be able to deliver any notices in this scenario due to limits with PPE use.
A: CMS continues to require Important Message to Medicare (IMM) and Medicare Outpatient Observation Notice (MOON) to beneficiaries, but hospitals should be creative with social distancing when sharing this information: We recommend that you transition momentarily to a charge nurse on that floor for delivery of IMM. It is not ideal, but if the nurse caring for the patient is already in PPE gear, they can do that as well. A UR/CM staff member may share the information with the beneficiary by phone, then have the nurse take signature the next time the patient is seen.
Q: Are there any concerns related to mental health inpatients or outpatients?
A: Many hospitals can waive the location of the mental health patient so those spaces or wards that are normally locked down can be used for patients who require isolation. Billing practices are also adjusting around that.
From the Editor: An Evolving Situation
As the COVID-19 pandemic continues, please refer to resources from CMS and the White House on proper response, protection and guidance on these and other issues. The Xsolis team is committed to serving you and our customer base through this time.