Medical necessity, not patient convenience, should drive inpatient stay, CMS warns

The perennial issue of medical necessity makes a grand appearance in recent CMS guidance you may have missed.

The agency sends a clear message: A patient's convenience or personal needs should not factor into a decision to admit him or her for an inpatient stay. It's a mistake that your friendly Recovery Audit Contractor will be on the lookout for – and which could earn you a retrospective payment denial.

Continuing a patient's hospitalization must be hinge on the safe delivery of the patient's care and on whether the patient's health or safety would suffer if the care were provided in a less intensive setting, CMS says in its updated "Guidance on Hospital Inpatient Admission Decisions." 

"Factors that may result in an inconvenience to a beneficiary or family do not, by themselves, justify inpatient admission," CMS warns.

Inpatient care, rather than outpatient care, is required only if the beneficiary's medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting.

"Without accompanying medical conditions, factors that would only cause the beneficiary inconvenience in terms of time and money needed to care for the beneficiary at home or for travel to a physician's office, or that may cause the beneficiary to worry, do not justify a continued hospital stay," CMS clarifies.

The message comes on the heels of a recent CMS announcement that it has increased to 500 the number of medical records that RACs can request during a 45-day period from certain hospitals.  

It's also part of new guidance CMS issued this week to try to deflect hospital concerns that its contractors are using analytic software to screen for cases they can deny. CMS admits its contractors do use screening tools, such as those from Interqual, Milliman and other vendors, to identify cases that may not qualify as medically necessary.

However, officials insist that the screening tools are only one of a half-dozen factors that affect the contractor's final decision to deny (or not). The final arbiter, they say, is the reviewer's clinical judgment.

For more information:
- learn more about the new medical records limit 
- read CMS' new guidance
- check out this take on the guidance
- read the FierceHealthFinance RAC Audit Survival Guide