Wiki Inpatient Authorization

[mschaller]

I was wondering if anyone knew where I could find some guidelines for compliantly obtaining authorizations. Here's the situation: We are an independent surgical practice who preforms operations at three different facilities. One of these facilities is giving us a hard time and threatening to cancel our cases for not obtaining inpatient authorizations. We as a practice generally follow Medicare guidelines. If the procedure is outpatient by Medicare guidelines we authorize and admit the patient as outpatient providing there are no comorbidities or extenuating circumstances that would call for an inpatient admission. The facility is requiring that we attempt to authorize all surgeries as inpatient regardless of the patients' conditions. I personally feel this is fraudulent. If the patient only requires an outpatient stay why would we ask for inpatient just so the hospital can make more money? The latest case we have is for a spinal cord simulator trial. Leads are percutaneously placed and patients generally go home the same day. In fact we often do these at surgery centers where there is not even the option to admit. The insurance will allow an authorization for a one day inpatient stay. It seems wrong to me to authorize this for inpatient simply because they will, when this is a very black and white outpatient procedure. Can any one offer any opinions or more importantly some documentation showing that this would be wrong. I'm worried we will be responsible for obtaining these authorizations and admitting patients when it is not necessary. Thanks!

 

[thomas7331]

I don't think you'll find compliance guidelines for authorizations for a couple of reasons - first, an authorization is usually a contractual requirement between the payer and either the patient or the provider, so would be governed by the terms of the contract and not by regulation; and second, an authorization is not a claim or request for payment or financial transaction of any kind and so, rather generally speaking, would not fall directly under false claims or fraud laws. Since an authorization is simply an advance notice or statement of intent to the payer of what the provider is planning for the patient, at which point no services have actually been rendered, I don't think it is legally binding on either party. In fact, as you're probably aware, most payers accompany an authorization with a disclaimer that it is not a guarantee of payment and that the final determination of payment won't be made until the claim is received.

That said, your question is a little confusing and seems to mix two issues, because asking your provider to get an authorization and asking them to admit a patient are two very different things. Admitting a patient to inpatient status who does not need inpatient care 'so that the hospital can make more money' would be providing medically unnecessary services at the very least and potentially unethical behavior by a provider at worst and that could be a compliance issue. But hospitals are usually under a great deal of scrutiny about inpatient admissions and I can't imagine they would ask this, let alone think that they could get away with it. But it does not sound like that is what the hospital is asking if they just want you to obtain an authorization. Perhaps the hospital wants an inpatient authorization as a preventive measure just to be covered in the event that the patient ends up having a complication during surgery and the provider makes a decision to admit them? If the hospital in the past has had denials because a provider admits cases to inpatient that were only authorized as outpatient, it can be costly and that could be what is behind this. I'm not sure that it's an most appropriate solution to the problem to get an authorization on every patient, but I don't think it fraudulent just to ask a payer for an authorization to cover a potential admission as long as you're not giving them any false information about the patient's condition or planned procedure. But it's a little unclear as to what exactly is being asked and I'd recommend talking this out with the hospital to get a better understanding of what they need and why.

 

[mschaller]

We have talked it out with the hospital. I am very clear on what they want but perhaps I'm not communicating it clearly in writing. I've always understood if an outpatient authorized service turns into an inpatient after surgery it is the facilities responsibility to inform the insurance and meet the medical necessity guidelines at that point. It just doesn't feel like we should be requesting a higher level of care for something we don't believe will need it.