Guest Post: POA: Episode II

by Lynne Spryszak, RN, CCDS, CPC

Preface to the following: You won’t find a stauncher advocate for ethical behavior in the documentation compliance profession than me. I firmly believe that documentation compliance is all about quality, specificity, and the behaviors and processes that support those aims.

However, we all also know that when it comes to implementing new initiatives it’s the bottom line that makes the decisions. That being said…

Once upon a time in a galaxy far, far away there existed an entity known as CMS, sometimes called the Empire. The Empire controlled everything in its purview, including hospital reimbursement.

Last year the Empire passed a new law called “Present on Admission (POA)”. All the citizens who reported to the Empire lived in fear of this new law but the first year passed without any significant battles.

Episode 2:
I suspected (as I’m sure you all did) that once the Empire announced that it would exclude payment for hospital-acquired conditions, it was only a matter of time before the commercial carriers followed suit. Guess what? It happened.

The Empire was able to recruit several allies. A quick call to our VP of Managed Care confirmed that our organization has received notification from ALL the managed care companies that they were either re-negotiating their contracts or adding a clause excluding coverage for hospital-acquired conditions. They’re all on board, only the dates of implementation differ.

How would the Empire and its allies make their influence known? I spoke with our Director of Denials Management to find out what type(s) of sanctions the managed care companies would impose; in other words, how would we not get paid? She told me that she was fairly certain that the carriers would deny the WHOLE claim when a hospital-acquired condition was on the bill and that it would be up to the organization to go through the appeals process to get paid.

I went on a fact-finding mission to see how many cases we might be talking about and what kind of money was involved. Was there a way to combat the forces of evil?

What started the whole investigative process was an interest in calculating how many FTEs, I mean, Jedi knights, would be required if our organization decided to do POA reviews on the non-Medicare inpatient charts. I didn’t think we’d have to look at every non-Medicare chart. After all, moms and babies barely get a chance to get the bed warm, much less acquire a complication. And most commercial patients aren’t in that long because the strict UR criteria of the Empire’s allies gets them discharged pretty fast.

So that whittled down the number considerably. I focused on finding out how many non-Medicare patients had a length-of-stay greater than 3 days. The final number was about 25% of the total number of non-Medicare discharges. Whew! I felt a little better. Jedi knights are hard to recruit.

I already had a data file for all the non-Medicare cases with a “N” POA indicator. I just had to look up the total billed charges on each account to get a feel for how much potential revenue might be pended for months at a time in the future.

Good thing I was sitting down! My goodness! It would require the combined forces of our little off-world population to fend off the enemy. Of course I can’t reveal any financial details; but let me say that it would pay for QUITE a number of POA reviewers, I mean Jedi.

There’s a saying that goes “an ounce of prevention is worth a pound of cure”. That just about sizes up the situation. You can hire a couple of reviewers to make sure that your conditions are documented appropriately or you can watch those cases get denied and fight to get the money back afterward.

If your administration isn’t aware of what’s ahead, this is yet another way to cement the credibility and value of your CDI program to your organization. A strong Jedi army can prevail against the forces of the Empire.

Editor's note: Spryszak, at the time of this article's release, was an independent HIM consultant based in Roselle, IL. Her areas of expertise include clinical documentation and coding compliance, quality improvement, physician education, leadership and program development.