Reprinted by permission from Elisabeth Hogue, Esq.; (877) 871-4062; ElizabethHogue@ElizabethHogue.net
MedPAC advises Congress about Medicare. The Remington Report in the October 4, 2017, edition of FutureFocus reported that a MedPAC staff member stated as follows at MedPAC’s September, 2017, meeting:
“The Balanced Budget Act (BBA) requires hospitals to provide beneficiaries with a list of nearby SNFs and home health agencies but the list is not required to have quality information….Medicare statute provides beneficiaries with the freedom to choose their PAC provider, the law states that hospitals may not recommend providers (emphasis added).”
Then in the March 7, 2018, edition of FutureForcus, a link was provided to a power point presentation presented by MedPAC on March 1, 2018. A slide entitled “Discharge planning is a hospital responsibility” that was included in the presentation states as follows:
“…Hospital discharge planners may not recommend specific providers-beneficiaries have freedom to choose PAC providers.”
Is it true that hospital discharge planners are prohibited from recommending post-acute providers to patients based on applicable federal requirements? The answer is a resounding NO!
The basis for the remarks of members of the staff at MedPAC seems to be Conditions of Participation (CoPs) of the Medicare Program that establish requirements for hospital discharge planning. Specifically, 42 CFR 482.43(7) says that hospitals must not specify or otherwise limit the qualified providers that are available to patients.
But making recommendations to patients about post-acute providers while emphasizing patients’ right to choose providers does not necessarily entail “specifying” or “otherwise limiting” the providers available to patients. In fact, such discussions seem to be required by applicable national standards of care the Case Management Society of America and sanctioned by the Centers for Medicare and Medicaid Services (CMS). Prohibiting these types of discussions also has practical implications for patients and their families.
Specifically, the Case Management Society of America (CMSA) first published Standards governing the practice of case management, including hospital discharge planners/case managers, in 1995. The Standards were revised in 2002, 2010 and 2016. Among other requirements, these standards require case managers to advocate on behalf of patients, including provision of assistance with making decisions about their care.
In addition, CMS sanctioned making recommendations to patients through the use of preferred providers. In final regulations of the Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services at 80 Fed. Reg. 73274 (November 24, 2015), CMS says on Page 73518: “We agree that hospitals should be allowed to identify preferred providers and suppliers…”
CMS goes on to say on Page 73520 that:
“…hospitals, if desired, may recommend “preferred providers,” that is, high quality PAC providers/suppliers with whom they have relationships (either financial and/or clinical) for the purposes of improving quality, efficiency, or continuity of care.”
Finally, anecdotally, hospital discharge planners/case managers often report that patients are unable to choose post-acute providers when lists are presented to them. In light of MedPAC’s comments above, it sounds like discharge planners/case managers are unable to provide assistance to patients except perhaps to hand them the equivalent of a copy of the yellow pages! From a practical point of view, this dog will not hunt! In fact, the “heart” of the discharge planning process includes recommendations from discharge planners/case managers about the best choices for patients. Patients are, of course, free to reject these recommendations.
Case management/discharge planning activities are at the heart of our healthcare delivery system. These crucial activities are finally receiving the recognition and “due” that they deserve. They should not be mischaracterized!
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