By Jeni Miller
Working to maintain compliance with Centers for Medicare & Medicaid Services (CMS) rules is a challenge. But when the messaging seems confusing or inconsistent, the task is that much more difficult.
One place where this is most obvious is in the CMS Discharge Planning Rule of 2019, as the preamble states that hospitals “must not develop preferred lists of providers.” Later in the Conditions of Participation under “For Information — Not Required,” the guidance explains that “hospitals would be well advised to develop collaborative partnerships with post-hospital care providers to improve care transitions that might support better patient outcomes.”1 These two areas appear to conflict with each other, leading case managers and hospitals to question how to proceed in caring for patients and their discharge needs.
“With anything that CMS puts out, there is often a little debate, but leading up to 2019 a lot of hospitals had invested a lot of time and energy in creating their preferred network of providers,” says Marmmett Horton, MSW, ACM-SW, CMAC, senior vice president and general manager, US, for Strata Health Solutions. “But then in the preamble to the final rule, it stated that hospitals should not be creating preferred lists of providers. Naturally, hospitals panicked about this.”
It was confusing to read that hospitals were not to curate a list of preferred providers, yet they were encouraged to establish a collaborative partnership with providers. “When things are presented vaguely, it creates an opportunity for interpretation for the surveyors who come out and review,” Horton notes.
Unfortunately, interpretive guidelines released by CMS have not been updated to include the 2019 rule, so case managers and hospitals have been left to figure it out on their own, resulting in hospitals across the country operating with different interpretations.
Compounding the issue is the relatively recent end of the waivers that were put in place in 2020. With the reinstatement, case managers need to reacquaint themselves with the rules and ensure that they are followed appropriately.
The first step to ensuring compliance with this facet of the Discharge Planning Rule is ensuring a process is in place to evaluate policies and procedures.
“The No. 1 thing that I recommend to hospitals is to make sure that having a provider list is built into the policies,” Horton says. “There is a requirement that it be documented in the medical record that the hospital has provided the list, and there should also be a copy of that list. It needs to be documented that the patient knows they have choices. An electronic tool can filter down to the patient’s insurance, geographic area, needed services, and more to replicate the list and show that this is what was provided for the patient.”
Interpretation of the rule always should reflect a patient-centered ethic. Showing patients a list that communicates which providers meet their stated needs and preferences is justifiable and appropriate.
“From a case manager perspective, the key is always doing what is right for your patients. That is first and foremost,” Horton explains. “When you’re focused on supporting their treatment goals and preferences, it’s hard to argue some of these other factors. There are even products that help look at compliance and can create a list and support that as well. The goal is to protect their freedom of choice and give them provider options that are true choices.”
Horton also mentioned that if a patient needs a specialty service, that should be included on the list. If they are enrolled in managed care, the case manager should let the patient know that there are specific networks that take their insurance and what those networks are.
“I think the word that people are missing in the preamble [for the Discharge Planning Rule of 2019] is that we must not develop preferred lists of providers,” Horton emphasizes. “In other words, we can’t limit the providers we present to a patient based on our own preferences. It always has to be patient centered. It can seem easy at times to default to someone convenient that you can work well with, and I think that’s what CMS was trying to prevent.”
Another important consideration is ensuring that the hospital is not defaulting to pushing patients toward an affiliated provider with whom the hospital has a financial interest. The responsibility is to provide all viable options to the patient to ensure they have true choice in the matter.
At the end of the day, hospitals can share a list and stay compliant. They are required to offer choices to their patients — if it is done with the patient’s best interests in mind.
“Hospitals are required to offer choice, and include quality and resource use data,” Horton says. “That’s a change — it used to just be required to provide a list, but now the requirement includes assisting patients in making their choice. We want to make sure they have all the information possible to make the best choice for themselves.”
Horton suggests case managers take advantage of all the professional education opportunities available to ease any apprehension about CMS rules and carry out the case management role. “Seek knowledge and ask the questions,” Horton says. “If you’re not sure, know that there are departments in the hospital that are looking into these issues and providing guidance. If you’re truly trying to do what is right for your patients, then you should be good. I know that as case managers we get busy day to day and can’t always stay on top of everything, but you want to grow in knowledge to support your patients, which is why most of us got into this.”
REFERENCE
- Centers for Medicare & Medicaid Services. Medicare and Medicaid programs; revisions to requirements for discharge planning for hospitals, critical access hospitals, and home health agencies, and hospital and critical access hospital changes to promote innovation, flexibility, and improvement in patient care. Fed Reg. Sept. 30, 2019.
Working to maintain compliance with Centers for Medicare & Medicaid Services rules is a challenge. But when the messaging seems confusing or inconsistent, the task is that much more difficult.
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