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Ethics of Admitting to In-patient (HELP)

  1. Default Ethics of Admitting to In-patient (HELP)
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    Hello. We are a general surgery group who provided services for the Lap Band procedure.

    We have always done this procedure as an out-patient....our patient's do not tend to stay in the hospital for more than a few hours after. UHC has now changed their guidelines stating that the procedure is not covered on an out-patient status...but they will cover in-patient.

    Our physicians do not feel that admitting these patient's is a medical necess. We have spoken with a nurse today from the insurance company and was told that we are making this a big deal and all we need to do is admit the patient to get paid. We stated this was fraud....they did not agree and said people do it all the time.

    Is this legal??? It sure seems wrong to admit a patient for a procedure that we feel is out-patient just to receive payment from an insurance company!!

    I need documentation to prove our stand on this....we have many patient's calling because the insurance company is telling them all we have to do is change the status of the patient..

    Please someone help!!!!!!

  2. Default
    have you tried talking to the Medical Director for that insurance company? Question why they feel it must be an "in" pt procedure since it is the surgeons feeling that the patient does not meet the criteria for in pt status. The Medical director may be able to give you some insight. good luck

  3. #3
    Louisville, KY
    I'd first check to see if this is a status indicator "C" service. That would indicate that the Federal payers consider it "inpatient only," which could be the source of UHC's decision.

    Unfortunately, this doesn't ring of "fraud" at all. I'm disappointed that the word has lost some of its effect from misuse. Regardless, the insurance company has a right to determine how its members will be treated, including whether it deems a service to be too high risk for an outpatient service setting.

    Truthfully, (from the facility side of the house) I wish more providers were savvy of what can be performed outpatient versus what the insurance companies expect as inpatient.

    Ask for their decision in writing and that should be all the documentation you need.

  4. Default
    Thank you both for your thoughts! I will check into these things.

    We were told that this guideline was picked by the employer John Deere and not that of the insurance company requiring it. Being that this employer spends a great deal stating they support the obesity and its treatment...its hard not to feel like they are creating loop holes for non-payment. We have not had a problem with lap band outpatient payments from UHC in the past...only with the new policy that has been created with this employer specifically. The funny thing is that this employer just switched from UHCRV to UHC chosing these tight guidelines. Not only are they requiring the main procedure to be inpatient.....but office fiills are also now required to be admitted....which means no maintance of the lap band will be covered. We surely cannot admit a paient to add fluid to these fills when these appointments take about 10 minutes in the office.

    You did state you do not feel changing this to meet the insurance requirements is fraud. I guess I just don't fully understand the guidelines in this area. All documentation shows that the patient should be "admitted" if there is concern regarding health issues and if you feel that the patient will be in the hospital 24 hours or longer. It still seems some what wrong to admit these patient's when we know laparoscopically treated these patient end up going home sometimes around four hours after procedure. This employer has set its guidelines so that no other surgeon in the area is covered under their plan for treatment....which puts us in a tight spot.

    Are we in fact over thinking this as the insurance company states? Should we just change our standards to meet the insurance companys policy for payment? Or does it really not matter if we admit the patient or do them as outpatient?

    Thanks again for all of your help!! Tracy

  5. #5
    Milwaukee WI
    Default Well ...
    It sounds to me as if this employer has decided they are only going to cover this service for those patients who are so ill from effects of morbid obesity (or other co-morbidities) as to require in-patient service.

    Perhaps your physician (or division chief, or practice CEO) should have a conversation with the employer's head of HR regarding this and the increased costs of the procedure (and other health-care) if you are going to wait until the patient is so ill before performing it.

    If the employer will not budge, then you will have to inform the patients that the service is NOT a covered benefit under their plan and that they will have to make arrangements to self-pay if they want this procedure (including the follow-ups).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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