Elizabeth Hogue on Identification of Patients in Need of Discharge Planning

Part I: Hospital Conditions of Participation for Discharge Planning: Identification of Patients in Need of Discharge Planning

Conditions of Participation (CoP’s) of the Medicare Program for hospitals include CoP’s for discharge planning. This is the first in a series of articles about these requirements. Hospitals that do not meet these requirements may lose their certification and ability to receive payments from the Medicare and Medicaid Programs.

CoP’s governing discharge planning first state that hospitals must have a discharge planning process that applies to all patients. The Centers for Medicare and Medicaid Services (CMS) says that the CoP’s it develops apply to all patients, not only to patients whose care is paid for by the Medicare and Medicaid Programs.

The CoP’s then say that hospitals’ policies and procedures must be specified in writing. Hospital discharge planners should review written policies and procedures required by the CoP’s to make certain that they reflect applicable requirements and current practice. Discharge planners/case managers may be required to demonstrate that they are following their written policies and procedures.

The first standard included in the CoP’s that must be met by discharge planners/case managers requires identification of patients in need of discharge planning. It states as follows:

(a) Standard: Identification of patients in need of discharge planning. The hospital must identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning.

This standard requires discharge planners/case managers to identify patients in need of discharge planning, regardless of payor source.  Hospital discharge planners/case managers are required to meet this standard and cannot rely on post-acute providers to identify patients instead.

Case managers/discharge planners who must comply with the CoP’s and post-acute providers that receive referrals from hospitals must be aware of a type of fraud and abuse with regard to this standard, i.e. kickbacks in the form of free discharge planning services. There is a federal statute, often called the “anti-kickback statute,” that governs illegal remuneration or kickbacks in the Medicare, Medicaid, and other federal and state health care programs. This statute generally says that anyone who either offers to give or actually gives anything to anyone in order to induce a referral has engaged in criminal conduct.

Possible penalties for violation of this statute include imprisonment, fines, civil money penalties, and suspension and exclusion from participation in the Medicare, Medicaid, and other state and federal health care programs. The penalties may apply to institutional as well as individual providers, so the stakes are extremely high.

The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services is the primary enforcer of fraud and abuse prohibitions. The OIG stated, in a Special Fraud Alert published in August 1995, that the activities of coordinators and liaisons supplied by providers who want referrals cannot supplant the services of discharge planners. When coordinators and liaisons perform services that discharge planners are supposed to perform, such as identifying patients in need of post-acute services, these services are kickbacks to referral sources in the form of free discharge planning services.

Case managers/discharge planners are “under the gun” to reduce the length of stay (LOS) at hospitals that employ them. It is tempting to rely on post-acute providers to perform activities that, according to applicable CoP’s, are clearly the responsibilities of case managers/discharge planners. Resist the temptation!

This material is provided to HCAF by Elizabeth E. Hogue, Esq. Contact by phone at (877) 871-4062, fax at (877) 871-9739 or email at elizabethhogue@elizabethhogue.net.

© 2012 Elizabeth E. Hogue, Esq. All rights reserved. No portion of these materials may be reproduced in any form without the advance written permission of the author.

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