Understanding Inevitable Unavoidable Delays
This article appeared on ICD10monitor.com on March 27, 2023
Delays in transitions to post-acute care are a vexing issue.
I am continuing to see a significant number of healthcare organizations dealing with denials and delays related to transitions to post-acute care. As such, I thought it would make a good topic for today’s article.
Delays related to transfers to post-acute facilities such as long-term acute care (LTAC), rehabilitation centers, or skilled nursing facilities (SNFs) are common across the country, and there are a couple of factors at play:
There is an internal hospital issue with over-referring to post-acute facilities;
Payors have intensified their review process prior to sending patients to post-acute care, as noted in an increase in delays, denials, and appeals; and
There continues to be limited staffing in post-acute facilities, causing a bed crunch.
In review of one of our client’s avoidable days, we are seeing these issues delay patients’ transfers to the tune of anywhere from 2-7 days, as they await placement in a post-acute facility and deal with their insurance company.
During the COVID-19 pandemic, hospitals were encouraged to send patients to other levels of care. The Public Health Emergency (PHE) waivers allowed hospitals to quickly move patients to post-acute facilities without prior authorization or the three-day inpatient stay requirement, in order to increase bed capacity. The trend was and unfortunately still is the mindset that “they no longer need to be here, so let’s free up a bed and move them to LTAC, rehab, or SNF.”
The payers do not practice this way; they are not concerned with your bed capacity issues. Since 2022, many payers started following post-acute InterQual criteria to authorize transfers to post-acute care, and any patients who did not meet the criteria were denied or required a peer-to-peer encounter. What payers are looking for specifically is, “why can’t the patient go home?” Then they will consider the next level up, or ask “why can’t this person have home health?” Then they will consider the next level. Reviewing physical and occupational therapy (PT/OT) documentation, their notes will make an optimal suggestion, but fail to consider why this could not have been in a lower care setting. For instance, yes, it would be great if every patient went to rehab, but that is expensive, and not always needed.
This is where case management comes in! A solid case management team should be able to work with PT/OT personnel, the physician, and care team, then make collective recommendations based on the assessment of the patient’s situation and the insurance factors proactively. However, case management has struggled as well over the last few years with turnover, short staffing, outdated models of practice, and lack of training (or, most likely, all the above). Many case managers are likely just facilitating the recommendations as they receive them and are unsure of what they can push back on. When this happens, the limited post-acute beds are being filled with patients who could have gone home, causing the hospital to hold patients longer because those patients who need the bed are stuck in the hospital waiting for transfer.
Yes, there is technology for efficiencies and guidance, but this is also indicative of a change of practice that is needed to unravel some of what was our best method – and became habit during the pandemic years.
Is your hospital or health system dealing with patients being denied transfers to post-acute facilities?