By Ronald Hirsch, MD, FACP, ACPA-C, CHRI, CHCQM
The Office of the Inspector General (OIG) of the Department of Health and Human Services recently made headlines with its report on the increasing rates at which Medicare patients left hospitals against medical advice (AMA). The OIG also compared hospital star ratings to their AMA rate and found an inverse correlation, with 1-star hospitals having three times the rate of AMA discharges than 5-star hospitals, implying there is a quality aspect to this. In addition, they found that dual eligible patients, those with Medicare and Medicaid, and those with a mental health diagnosis left hospitals against medical advice at a higher rate than patients without Medicaid or without a mental health diagnosis, and that those who go against medical advice are readmitted more often than patients who do not leave AMA.
Notably, the OIG chose not to include patients enrolled in Medicare Advantage (MA) plans, even though there are now more Medicare beneficiaries enrolled in Medicare Advantage plans than in traditional Medicare. In addition, CMS receives shadow claims for all Medicare Advantage admissions, enabling them to determine the rate of AMA discharges for MA patients easily. Furthermore, dual-eligible patients can enroll in Medicare Advantage with Medicare Special Needs Plans.
The OIG does correctly point out that while there are ICD-10-CM codes in the Z53.xx range that can be used to indicate the reason a procedure or treatment was not carried out, which could be used to indicate the reason a patient leaves the hospital AMA, there is no National Uniform Bill Code claim completion requirement for such a code. They do note that in their data, 23% of the AMA discharges did include such a code. They also correctly note that while many hospitals ask the patient to sign an AMA form, such forms may not alleviate all liability from the hospital and providers.
Additionally, the OIG admits that CMS “could not offer any clinical, regulatory, or professional standards to guide hospitals on when to designate that a patient is leaving AMA, other than citing the use of clinical judgment. In addition, CMS has no guidance on what discharge planning and follow-up steps are expected when a patient leaves AMA.”
In their conclusion, the OIG was careful to point out that their report presents the data as it exists, and they make no attempt to draw any cause-and-effect relationships nor make any conclusions about necessary actions. They summarize with “Finding ways to reduce the rate of enrollees who leave AMA or the poor outcomes these enrollees suffer when they do leave AMA will likely improve the health of the Medicare enrollees and save Medicare costs.”
What conclusions, though, can be drawn from this report? Let me present some options. First, it is certainly possible that the increase in AMA discharges represents better claim coding by hospitals. The CMS Hospital Readmission Reduction Program has brought readmissions to everyone’s attention. When a patient chooses to leave the hospital against medical advice, the placement of the discharge status code 07 on the claim means that if the patient does get readmitted to that same or any other hospital, which the OIG has pointed out is more likely, the readmission will be excluded from the penalty calculation.
The increase in AMA discharges could also represent a change in thinking by providers. In the not-so-distant past, it was felt that if a patient was choosing to leave AMA, no discharge planning could be provided to that patient. As a result, physicians went along with the patient’s less-than-optimal plan so that they could still offer prescriptions, arrange home care, and order other tests and services as necessary. That myth has now been dispelled, and a patient can still leave AMA with the necessary post-hospital arrangements made. With these “collegial” AMA discharges, the doctor would document the fact that the patient is discharging against their advice, along with the plans for the patient.
This increase could also represent a growing problem in almost every hospital around the country- a problem with capacity. Patients may be leaving AMA because they are feeling somewhat better but are tired of being stuck on a gurney in the ED hallway for days on end when there are no open inpatient beds in the hospital.
However, the most significant aspect of this report is the OIG’s observation that there are no regulations governing the use of the AMA designation. And I would argue that we are using it far too infrequently. Every day in every setting physicians make recommendations to patients about their care, be it prescribing a medication, ordering a test, performing a procedure, admitting them to the hospital. And patients have as a core ethical principal autonomy to accept that recommendation or reject it. When a patient is prescribed 10 days of an antibiotic but chooses to stop after 6 days when they feel better, they are acting against medical advice. So when the hospital medical team advises a patient to go to a SNF for rehabilitation but the patient insists on going home, that is the patient acting against medical advice. And applying the discharge status code 07 to the claim is appropriate.
As noted, the designation of AMA excludes an admission from the Medicare Readmission Reduction Program but also from most payer’s readmission payment programs. Unlike traditional Medicare where a readmission is paid as a full DRG but is used to calculate the subsequent readmission penalty, many payers twist the Medicare rules into a policy that either denies payment for that second admission entirely or demands the provider combine the two stays into one claim unless the patient left the hospital against medical advice and the claim was coded as such.
What can be the result? Imagine the patient is hospitalized for several days with an acute medical condition. The patient’s functional status at home prior to discharge was poor and they had little or no family support. The patient has further decline of their functional status during the hospital stay and struggles to get to the bathroom. The physical therapist evaluates the patient and recommends a brief stay at a SNF to regain strength and mobility as the patient recovers.
The case manager then contacts the patient’s Medicare Advantage plan which denies SNF transfer as “the patient can get adequate therapy in the home.” The attending participates in a peer-to-peer call with a payer medical director who refuses to disclose their name or medical specialty, but the call is unsuccessful. The patient is informed and does not want to pursue an appeal so home care is ordered and the patient discharged. A week later the patient is brought back to the hospital after falling at home and fracturing their hip. The MA plan informs the hospital that they must combine both admissions as “per the plan readmission payment policy.”
In that light, hospitals need to take another look at their Medicare Advantage patients where the provider is clinically appropriately requesting a specific type of post-acute care, be it transfer to a inpatient rehabilitation facility or a long term acute care hospital or even to a skilled nursing facility and the payer is denying the authorization for such and approving a less intense care setting, resulting in a discharge that is “against the clinical judgment of the provider.” And as such, the discharge can be compliantly coded “against medical advice.” The provider, as a contracted provider, may agree to order discharge and complete the necessary paperwork, but it is still against their clinical judgment.
This code on the claim then excludes the admission from the payer’s policies on readmission payment if the patient subsequently returns to any hospital and is readmitted. The hospital can also use ICD-10- CM code Z53.8, Procedure and treatment not carried out for other reasons, to indicate on the claim that indicated treatment, in this case transfer to the clinically-determined appropriate level of care, was not provided, with documentation from the case manager and provider indicating the reason for the modification in the discharge plan. Sadly, there is no code at this time for “refusal of payer to cover medically necessary care.”
The OIG is correct to suggest an analysis of the increasing numbers of patients who are leaving the hospital against medical advice. To do so properly will require a review of medical records and even patient interviews to truly understand the reasons why patients choose to not follow medical advice. And hospitals should welcome such scrutiny as it will reveal that many such patients choose to do so not because of provider deficiencies but because of systemic impediments to receiving the right care in the right setting.
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Bio: Dr. Ronald Hirsch is a Vice President of the Regulations and Education Group at R1 RCM Inc. Dr. Hirsch was a general internist and HIV specialist and practiced at Signature Medical Associates, a multispecialty practice located in Elgin, IL. He was Medical Director of Case Management at Sherman Hospital in Elgin, IL from 2006 to 2012, where he was Chairman of the Medical Records Committee from 1995 to 2012, and also served on the Medical Executive Committee. Dr. Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians, certified in Revenue Integrity by the National Association of Healthcare Revenue Integrity, and on the Advisory Board of the American College of Physician Advisors. He is on the editorial board of RACmonitor.com. He is the co-author of The Hospital Guide to Contemporary Utilization Review, with the third edition published in 2021.