Lessons Learned in the Shadow of COVID-19

With hospitals brimming and often overflowing with sick COVID-19 patients, 2020 was a horrible and relentless year for healthcare workers. Caregivers were burdened and endangered as more than 2,900 healthcare workers lost their lives to the pandemic. 2021 brings us hope, promise, and protection, but with daily new cases hitting all-time highs, there is much more work ahead.

Compounding matters, hospital finances are severely stressed. Systems as large as the Cleveland Clinic and as small as 25 bed Ozarks Community Hospital have suffered financially. A Kaiser Family Foundation study estimated that the average cost to care for a hospitalized COVID-19 patient is, on average, more than $20,000 and could cost up to $88,000.  Hospitals are our community frontlines for fighting diseases; we need to help stabilize them and ensure their health. It is paramount that providers do all they can to get the best, fairest reimbursement for COVID-19 care.

Proper reimbursement begins with proper documentation. As with all hospital conditions, it’s critical to document the condition (i.e. pneumonia) then link it to the cause, COVID-19.  Detailed documentation of COVID-19 infection will lead to a higher weighted DRG and higher DRG payment. Of course, a higher DRG payment is only meaningful if the patient is in inpatient status. Therefore, documentation to support inpatient status is vitally important.  Dr. Marina Farah, a Physician Advisor with Sound Advisory and principle for FarahMD Consulting, notes:

“Good documentation is the only defense against COVID-19 denials. It’s crucial to document oxygenation on room air, physician findings (such as) accessory muscle use, risk factors for progression to severe disease and why isolation cannot be performed at a lower level of care.”

Dr. Farah further points out some challenging issues with commercial payer denials:

“I have seen a few COVID-19 denials because of outdated MCG definition of hypoxia for COVID-19 patients (i.e., pulse ox < 90% vs ≤94% per IDSA guidelines).  In contrast, the Infectious Diseases Society of America (IDSA) defines severe COVID-19 infection as “patients with SpO2 ≤94% on room air, or patients who require supplemental oxygen, mechanical ventilation or extracorporeal mechanical oxygenation.”

IDSA guidelines recommend the use of remdesivir among hospitalized patients with severe COVID-19 (defined as patients with SpO2 ≤94% on room air, or patients who require supplemental oxygen, mechanical ventilation or extracorporeal mechanical oxygenation). Among patients with severe COVID-19 on supplemental oxygen but not on mechanical ventilation or ECMO, IDSA suggests treatment with five days of remdesivir. Such care would extend beyond a reasonable period of observation. Dr. Farah has successfully used this information to overturn a claim denial for a COVID-19 inpatient stay.

Apart from the documentation of care, hospitals now have access to additional funds to underwrite their COVID-19 care. The Federal Government and CMS have provided multiple waivers and new programs to this end, including:

• Financial relief to physicians, hospitals, and other providers during the COVID-19 pandemic through the CARES act. (for eligible physicians and organizations, the payment will be at least 2 percent of reported gross revenue from patient care).
• A portion of the Provider Relief Fund to reimburse healthcare providers, at Medicare rates, for COVID-19-related treatment of the uninsured.
• Add-on payments in the inpatient and outpatient settings for COVID-19 therapeutics such as remdesivir.

Beyond these new sources of additional revenue, providers have learned that it’s not just about extra dollars but also about developing creative solutions to allow earlier discharge for stable COVID-19 patients. Such actions will reduce expense, not to mention free up vital bed space. The Care Coordinator Department at Dignity St. Joseph Hospital in Phoenix, in collaboration with Sound onsite Physician Advisor Lisa McClellan, created such a program.

When COVID-19 first hit Arizona, it hit the Navajo reservation particularly hard.  Many of those patients landed at the tertiary care St. Joseph’s Hospital, some 300 miles away. Due to the distance and tribal licensing requirement, transport back to the reservation was nearly impossible to arrange. Dr. McClellan, working with Navajo Nation Case Managers and the IHS Chief Medical Officer for the Navajo Area, developed some unique arrangements for transportation. Due to this arrangement, many stable Navajo COVID inpatients at St Joseph’s didn’t remain alone and far from their homes and families but could travel back to the reservation.

In another example of innovation to reduce length of stay and therefore minimize expense, the Care Coordination Department at St. Joseph’s established close communication and collaboration with local areas Skilled Nursing Facilities (SNFs).  Daily, the department knows who is taking COVID-19 patients and how many beds are available. Patients who are stable for transfer to a skilled level of care can now transition out of the hospital. That’s a far cry from the initial state earlier in the pandemic when the usual answer from a SNF regarding accepting a COVID-19 inpatient was “No.”

Looking ahead, hospitals have had to figure out how to manage extraordinary demand that stretches the limits of bed capacity. That reality has forced them to continually attend to the forward movement of patient care and throughput. This pandemic will end, and unfortunately, its impact on finances and staff health and morale will linger. Hopefully, hospitals will recognize that these lessons learned from the COVID-19 pandemic will be critical success factors for the future. There will be a continued “squeeze” on hospital finances for the foreseeable future.

COVID-19 has taught hospitals that keys to future financial survival include:

• Strong, consistent documentation to support the highest and fairest reimbursement for care.
• Collaboration with outside agencies and providers to help move patients out of the hospital more rapidly.
• A general attitude of forward-movement to safely discharge patients so that beds can open up for future patients.

Excellent care for an individual COVID-19 patient is essential, and optimized hospital workflows and processes are vital for long-term hospital vitality.

For questions or more information, please email advisory@soundphysicians.com.

Related Content

To view the webinar, COVID-19 Admissions: Getting Status Right & Preventing Denials, recorded in May 2020. Click here.