Editor's Note

Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI

Member, ACPA Advisory Board

Member, ACPA Government Affairs Committee 

Editor, ACPA Update

Thanks to all of you for allowing the newsletter to have July off. Summer used to be a relatively quiet time but as I am sure you all have seen, we are in a new normal since March 2020 and nothing seems to be the same.

We have a long issue this month so I am going to keep my comments short. First, do the Observation committee cases of the month. Really. Hundreds of you get this newsletter yet only a handful ever answer the survey. Think about your colleagues who take the time to conceive and write these cases. It will take all of 4 minutes and 35 seconds to read the case and answer the questions. In fact, just click right here and do it now.

Second, I am very dismayed about the increasing violence against health care workers. I am going to get politically incorrect and say that I blame some of it on the doctors who I will call “anti-vaxxers” who have built their fame and fortune opposing vaccines, masks, and conventional treatments while selling quackery throughout the pandemic. They have built immense social media followings that no longer trust the conventional medical providers and feel empowered to act with violence. I will admit that some violence has existed prior to this, with patients spitting, kicking, punching nurse or doctors when they don’t get their way. No violence should be tolerated. Find out what your health system policy is on violence and be sure the safety and well-being of all your co-workers is protected. If I was still working at the bedside, I would not hesitate to call 911 if a patient assaulted me in any manner so our legal system could determine the proper recourse. Rant over.

Now, go ahead and read this month’s articles. They are great. Thanks to all the authors who submitted articles. I am still waiting for yours.

Remember, ACPA is here for you. Tell us what you want, what you need, and what you can contribute. You can always contact me at signaturedoc@gmail.com. 

Medicare Two-Midnight Rule Exceptions (Short Stays)

Deborah Greer, MD

ACPA Government Affairs Committee

Physicians can struggle with the concept that Medicare patients that cross less than two midnights have inpatient status based on the determination of the severity of illness and intensity of services. For example, if a patient received a diltiazem drip for rapid atrial fibrillation, in the mind of some physicians, this situation would automatically count as inpatient even if the patient was discharged the next day. This may have been the case prior to October 1, 2013, but with the implementation of the two-midnight rule by CMS noted in the 2014 Inpatient Prospective Payment System (IPPS), a physician expecting the patient to cross two midnights with the medical records supporting that expectation would be able to pay under Medicare Part A. Patient stays less than two midnights may possibly be paid under Medicare Part B but not A, whether if placed as outpatient from the onset, if changed to outpatient via the condition code 44 process, or via self-denial and rebilling after discharge. 

Following release of the rule, CMS received extensive feedback from stakeholders, and in order to clarify updated the rule with CY 2016 OPPS Final Rule addressing hospitalized exceptions of less than two midnights. They added the Case by Case exception at that time to the exception for inpatient only list procedures and newly initiated mechanical ventilation. 

The list of patients that may now be compliantly billed to part A is:

• Procedure/Surgery on the Inpatient Only List
• Case by Case exception if the medical documentation supports the physician’s determination that despite a lack of 2-midnight expectation, the patient requires an inpatient level of care. Consideration can be for history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.
• Newly Initiated Mechanical Ventilation
• Unexpected Circumstances that interrupt an expected 2-midnight stay:
• Transfer to/from another hospital
• Death
• Rapid clinical improvement
• Transitioning to Hospice/Comfort Care following active or the intention of active treatment

Knowledge and documentation are predicated on the successful appropriateness of the inpatient short stay. There are instances where the surgeon/proceduralist will place an outpatient order for a procedure on the Inpatient only list, and the inaccurate order is not caught until the patient leaves the hospital building. This exception would be an easy inpatient stay if the correct CPT code was documented in the outpatient setting and transferred to hospital billing. Patient financial services/admitting then ensures the physician status order is indeed inpatient with care coordination as secondary support and reviewer. Communication is key, especially if the procedure is new to the hospital and the procedure is not known to be on the Inpatient only list.

For case-by-case and unexpected circumstances exceptions, medical documentation that supports the physician’s decision for the exception is vital if an audit occurs, whether internal or external. Rote notes written either as a short “dot phrase” or a copy carry can affect the final determination of appropriateness. For unexpected circumstances, there must be documentation of why the patient requires inpatient status, including an expectation of the hospitalization crossing 2 midnights in the History & Physical. If there is rapid clinical improvement, information that is sought would be, what were the severity of signs and symptoms, the treatment that required the patient to stay two midnights, and how the patient improved and can now be discharged.

Continuous education to reinforce thoughtful documentation provides a tangible account of each decision made in the course of patients’ care which further supports Medicare exceptions based on medical necessity under short stays. This ensures accurate reimbursement, decreases poor audit results, and improves patient safety and quality of care.

“Knowledge is not power; it is only potential. Applying that knowledge is power. Understanding why and when to apply that knowledge is wisdom.” – Takeda Shingen

Dr Greer is Medical Director, Advisory Services at Sequoia Hospital

How to Make Positive Progress with Your Executive leadership: The Power of the P’s

Stephanie Van Zandt, MD, CHCQM-PHYADV

Co-Chair ACPA National Physician Advisory Conference 

Like many of you, I find myself amidst the chaos of a post-pandemic era, grappling with rising observation rates, soaring denials, challenging patient throughput, and scheming MA plans - issues plaguing health systems across the country. My executive leadership has made it very clear that our health system needs an all-hands-on-deck approach to address these challenges. Our primary objectives for this year are to achieve 3 short-term, immediate solutions, while also initiating 3 long-term strategies to right-size our length of stay and observation rates. Senior executives have enlisted the expertise of outside consultants and engaged various VPs and CMOs to champion pilots and projects. Occasionally, they remember to invite me or my clinical physician analyst to the meetings. (It’s not as if we haven’t been advocating the same message since before the pandemic.) As with most healthcare systems, our most significant deficiencies lie in the entrance and departure processes within our acute care space. Rectifying these transitions of care necessitates an upfront investment of resources to combat the utilization management nightmare we currently face.

But when you don’t get a seat at the table, how can you ensure that your boots-on-the-ground, sage advice reaches the ears of the C-suite? The answer lies within the power of the Ps! 

First, it’s about PERSEVERANCE: recognizing that effectively conveying an impactful plan to your executive leadership is a long process filled with setbacks and disappointments. Resist the urge to succumb to despair when your polished presentation on observation solutions or proformas regarding the ROI of a physician advisor program gets derailed by irrelevant questions and sidelined. Stay determined and try again. Find the right audience who will appreciate and understand your message.

Moving on to PURVIEW: Utilize your expertise to gain trust and influence. Find an analyst to help you leverage data and create metrics-driven action plans. Usually, data talks but if that does not work, then find a champion among the executive leadership who understands your message. 

Next is PERSUASTION: Keep reiterating your message and they may hear you after the third time! And proactively invite yourself to important meetings where you know your message needs to be heard. Leverage your champion to secure a seat at the table, if necessary. 

Moreover, PERCEPTION matters: Make sure you deliver transformative and relevant value. Be easily accessible and readily available. Aim to provide services to a wide range of stakeholders, making yourself indispensable so that they cannot operate without you. Collaborate with finance to establish a common ground for sharing information, allowing both parties to feel connected and aligned. Additionally, engage with managed care leadership during contract negotiations to advise on favorable language for avoidance of excess denials and readmission penalties. However, never lose sight of your primary team—the utilization review nurses and their leaders—together you can drive meaningful change.

The key is to maintain a POSITIVE outlook despite the challenges and cut yourself a little slack. It’s important to occasionally take a moment to reflect on your accomplishments and ensure that executive leadership is aware of them. Remember, we are more than just a secondary review! Demonstrate your PASSION by emphasizing and showcasing your value as a skilled negotiator, analytics wizard, compliance expert, documentation and coding specialist, and educator. Above all, remember you are the only one who can truly determine medical necessity. And always bear in mind, the power of the Ps is at your disposal.

Dr. Van Zandt is Medical Director Physician Advisor Services/Utilization Management/Complex Managed Care Denials at BayCare 

The Medicaid Redetermination – Hanging Off the Edge of the Cliff

Day Egusquiza

Member, ACPA

The end of the COVID-19 public health emergency brought with it the end of the broadened criteria to qualify for Medicaid and the need for those Medicaid beneficiaries to requalify to retain Medicaid coverage. Many had predicted that there would be a large group of existing Medicaid patients who would not requalify for Medicaid once the redetermination/rescreening had begun. It was thought the largest group would move to commercial insurance (over the last 3 years, had a job that offered insurance) with the remainder who did not qualify being moved to the Marketplace/Exchange with assistance with premiums and deductibles for lower income enrollees – too much for Medicaid but not able to afford regular insurance. 

What was likely greatly understated was the way that each of the states could decide on their own process for screening/which group to do ‘auto’/ which group to do first, etc. and that the majority of the ‘rejections for coverage’ would be from what is referred to as procedural/administration issues. Wow- the volume of patients being moved off coverage is astounding. How will the patient know how to get re-evaluated for coverage? There are very specific timelines to protect coverage while the appeal is occurring (15 days from notice) and then 90 days for appeals. One of the primary reasons was the patient did not have a good address so the notice for required information was not received; the patient did not have all the required financial information as Medicaid is an income based program.

With the magnitude of rejections – averaging 75% of all applicants being rejected nationwide for procedural issues – the financial, mental and emotional health of our patients is being severely impacted. The redetermination process required each state to do extensive outreach to prevent inappropriate denials. Unfortunately, the Kaiser Family Foundation ‘s survey in early summer found approximately 65% of the Medicaid population did not realize this was happening.

The patient stories of care being discontinued – for children in ongoing treatment, appointments being cancelled as no insurance - all are concerning.

What is the role of the healthcare provider to assist each pt in their overall understanding of what is occurring? How can the internal Patient Financial Navigator lead the hospital’s, provider, other healthcare providers with a defined set of outreach to assist with finding coverage or filing an appeal, to try to prevent coverage gaps?

The potential increase in bad debt is significant. 

The action to reduce this while being proactive to reach out and prevent more procedural denials can be mitigated by a powerful internal, organized provider outreach effort. It will more than pay for itself!

When we think about the mission for our PFS team, mine was always:

“My patient did not ask to be sick

My patient did not ask to have their life disrupted.     

My patient did not ask to have their insurance pay so little or nothing at all

My patient is sick and scared. 

How can I help you navigate thru the Business of Healthcare?”

The Medicaid Redetermination process is one of the most significant public health challenges healthcare providers and community outreach is facing. We can help!

Day Egusquiza is Founder and President of AR Systems, Inc. & Patient Financial Navigator Foundation, Inc.

Let’s Speak the Same Language in Denial Management

Denise Wilson

Member, ACPA Advisory Board

Successful denial and appeal management includes placing every denial in a category that defines the overall issue at hand, such as coding, clinical validation, medical necessity, and so forth. Categorizing denials is especially important for reporting purposes because it can give providers insight into payer behaviors, root causes, opportunities for improvement, and payer and provider accountability. If we are ever going to be able to do peer-to-peer comparisons on a broad scale that provide at least as much believable data as possible, we have to speak the same language. At your organization you might refer to the denial categories as issues or as denial rationale, or some other nomenclature. In this article, I’m going to use the terminology denial categories. 

Medical necessity is a denial category that has many meanings and I think it’s time we all get on the same page as to what is meant by a medical necessity denial. Medical necessity can mean the procedure or service was not medically necessary to diagnose, treat, or maintain a patient’s health. Medical necessity denials for procedures or services, and by services, I mean drug administration, physical therapy, home oxygen, etc., can be associated with inpatient or outpatient care. But medical necessity is also very often used by payers and providers to mean the medical necessity of an inpatient admission to the hospital. This double meaning can lead to confusion over what was denied. Take the patient that was admitted as an inpatient from the Emergency Department after an episode of severe bradycardia with syncope who then has a permanent pacemaker inserted. The payer denies the claim as not medically necessary. What wasn’t medically necessary? The inpatient admission or the procedure or both? The provider is left with trying to pin the payer down on what specifically was denied or appealing both the admission and the procedure. My recommendation is that the medical necessity denial category be used for procedures or services deemed not medically necessary by the payer.

Level of care is often used as a denial category. The term, level of care, is used in different ways depending on the purpose and audience. Level of care can mean inpatient versus outpatient status when a patient is in a hospital bed. But level of care can also be used to identify denials related to the level of care within a hospital setting such as ICU or Level 3 Neonatal Care. Level of care denials are often lumped into medical necessity denials because the intensity of the medically necessary services required by the patient is one key factor in determining the appropriate level of care for the patient. 

Payers who reimburse based on a per diem rate may deny the level of care (ICU care versus general medical care) during specific inpatient days. This results in a downgrade in payment. Instead of paying the contracted rate for an ICU care, the payer reimburses the contracted rate for general medical care. The payer’s denial rationale is that the patient’s care needs on a particular day did not require the higher level of care.

Now, if we use the terminology level of care to also describe denials of inpatient status, then the meaning of level of care becomes less precise. Does the number of denials under the level of care denial category on your denials report represent both the denials for inpatient status as well as the per diem denials for the level of care? I am proposing that level of care as a denial category represent only level of care reimbursement reductions, such as from ICU care to general medical care. 

So, that leaves denials for inpatient status versus outpatient status (with or without observation services). What if we used patient status as the denial category name for these types of denials? I’ll bet you could say patient status to anyone involved in denials and appeals and that person would know immediately what you mean. I suggest that denials for inpatient status be referred to as patient status denials. Wouldn’t that be clearer than saying medical necessity or level of care?

So, for medical necessity denials, think – is it level of care, patient status, or medical necessity of procedure or service? Categorize thoughtfully so that we can all be on the same page.

Denise Wilson is Senior Vice President, Clinical Appeal Services at PayerWatch

CMS-4201-F – The Medicare Advantage Rule - Questions and Answers

Dr. Khiet Trinh

Member, ACPA

Can you talk a little bit about how the rule came to be?

Medicare Advantage (MA) programs have exploded in market share over the past decade or so. These programs implemented coverage criteria that were often different, more stringent, than traditional fee-for-service Medicare. A noticeable effect was the rise in the percentage of patients in a hospital that were hospitalized as observation. As this trend continued, operating margins of health systems started to dwindle.

As background, in 2013, Medicare attempted to simplify for clinicians whether to hospitalize a patient as inpatient or outpatient (with observation services). This resulted from legal actions from beneficiaries who were concerned they were being kept observation when they should have been inpatient. This is important because as an inpatient you have certain rights, such as appeal rights and Skilled Nursing Facility (SNF) coverage rights. There were also greater financial liabilities as an outpatient versus being inpatient. Therefore, CMS implemented the Two-Midnight Rule. For the first time, a patient's status was no longer just about intensity of service or severity of illness – it is actually based on time, and more specifically the number of midnights a patient was expected to spend in the hospital for hospital care. Ostensibly, this was a welcome change because it made it much easier for physicians. They could look at their watch and say “Okay, you stayed two midnights for hospital services, or I expect you to stay two midnights so I can make you inpatient.” 

But MA never went that road. They said “Nope. Our contract with CMS allows us to create our own criteria for inpatient versus observation (OBS).” So we have been urging CMS – writing commentaries, speaking to leaders about the unfairness of some of the criteria used by MA – and finally this year on April 5th, after a comment period, CMS has come out and said that they want to clarify that MA plans must follow the Two-Midnight Rule. We’re excited because it makes our lives easier, and could improve the patient experience as well, in the sense there may be less status changes as the rules are simpler. 

Can you talk a bit more about the administrative burdens that the old way caused?

It's an enormous administrative burden on hospitals to have different standards between fee-for-service Medicare and MA plans. Hospitals are left to navigate the different criteria that may exist between different MA plans. And then of course, all the peer to peers and appeals to argue medical necessity when they deny are very resource intensive. Add to this the different notices, submissions, and other nuances required just to get paid for care provided for their member, and the burden becomes overwhelming and expensive. Of course any slip-up, will result in the dreadful “technical denial”. To be clear, even with this new rule (known as CMS-4201-F), most of these processes will remain, but a standard inpatient criteria is most welcome for those of us in Physician Advisory.

What is the impact of this rule on hospitals, patients, etc.?

I do foresee an increase in inpatient status at discharge. The average length of stay for a hospitalization in America is about 4.5 days. This naturally crosses two midnights. Before CMS-4201-F, OBS patients could be languishing many days in OBS because they didn't “meet” MCG or they didn't “meet” InterQual. Now, if you're receiving medically necessary hospital services after two midnights, you should be upgraded to inpatient. I think that's really important. 

While the Two-Midnight Rule is the headline, there are other important parts of CMS-4201-F. For example, in 2016 a big rule came along that said you actually don't have to stay two midnights – it's called the “case-by-case exception” through which if a doctor thinks you need to be inpatient because you're at such a high risk, but doesn’t expect you to stay two midnights, it's still okay to admit that patient as an inpatient. That also now applies to MA plans. 

Another big one is that the Inpatient Only List (IPOL) also now applies to MA plans. This was one example where CMS actually made things easier and said that if the procedure you have is on this IPOL, then you will get inpatient payment regardless of how long the patient stays, provided there is an inpatient order. Again, previously MA plans had their own criteria for surgical statusing and none of them really followed the IPOL. But now, CMS is clarifying that MA plans also have to follow IPOL. 

The other big thing is SNF coverage. If a patient would qualify for SNF coverage under fee-for-service Medicare, now MA plans would also have to qualify. These are seismic changes, in my world at least. 

Overall, it is great to have this clarity. Whether you look at it from a hospital standpoint, a patient standpoint or as a physician, it's not only clarifying, but it's simplifying criteria, at least on the surface. 

What is the financial impact of all of this?

I believe that from a financial standpoint there may be an opportunity to classify more patients as inpatients than before. To hospitals this is a positive as inpatient generally pays more than observation. There is also financial impact to patients. For example, if you are hospitalized as observation, you have to pay coinsurance each time. Additionally, certain medications that you take in the hospital may not be not covered. Essentially if a patient comes in for observation/outpatient, they are at more financial risk because their coinsurance applies each time they go to the hospital, and because their medications given during the stay may not be covered. Whereas if they are considered inpatient, Medicare will pay for the stay, including medications, for the first 60 days after the deductible has been met. 

Importantly, if an inpatient disagrees with discharge, they’re able to appeal to the Quality Improvement Organization (QIO). Those are rights that are only afforded to inpatients. So by ostensibly making inpatient easier, these rights are now restored to patients who previously would have been OBS.

Do you feel like this better aligns with your decision making as a clinician – that you’re able to go with what you know is right for these patients versus fighting with the insurance companies that don't have clear criteria set for why or why not they be reimbursing in a certain way? 

Absolutely. CMS has always deferred – and they remind us in this latest regulation – that the decision to admit is a complex medical judgment to be made by the physician. This is really important because before the Two-Midnight Rule it was based on commercial criteria. Criteria may say if a patient gets a certain rate of IVF, a certain number of packed Red Blood Cells, a certain liter of oxygen, etc, they can now be inpatient. That's silly to a doctor at the bedside, right? They should be able to look at the entirety of the patient, including the presenting symptoms, labs, x-rays, physical exam, risk of adverse event and say, “In my judgment this should be inpatient.” Not only that, but when you see somebody spend days and days in OBS just because they didn't “meet criteria”, it can be very frustrating.

Now a doctor can say, “I expect, in my clinical judgment, this patient to stay two midnights or two midnights have passed for hospital level services. I now can confidently make this patient inpatient.” So for the physician at the bedside, it does bring simplicity. I can guarantee you 90% of bedside physicians have no idea how to work commercial criteria tools. The Two-Midnight Rule should make more sense to these same physicians. 

How common are MA plan denials happening? How prevalent is the problem?

The OIG looked at denials from 2014 to 2016. What they found was only 11% of these denials were ever appealed. However, the MA plan themselves overturned 75% of these appeals. It's infuriating. To me, that would indicate there are too many inappropriately denied services to begin with. Once you push back, the vast majority got overturned. 

But I don't think it was ever intended that MA plans would wield this kind of latitude to deny, and in fact the language being used is that MA plans cannot be more restrictive in covering traditional Medicare benefits than Medicare FFS. So I think that the language was always there and CMS-4201-F clarifies, enforces, and codifies this key point.

What is the next fight or the next big change where we need to focus our efforts?

After myself, and many others, wrote letters during the comment period to CMS supporting the Two-Midnight Rule, many of us then wrote a second letter about the need to reform the prior authorization process. Remember, different payers have different prior auth processes and algorithms. This causes tremendous administrative burdens for all involved. Even more alarming, there may be direct patient harm due to delays in starting treatment plans as we wait for approval. Simplifying prior authorizations should be our next goal.

Dr. Trinh is the Chief Clinical Officer and Chief Physician Advisor for Ensemble Health Partners

Observation Committee Case of the Month

Provided by the Members of the ACPA Observation Committee

Determining the admission status for patients having surgery is often difficult. It becomes even more difficult when the planned surgical course changes. This month’s case addresses just that. 

Seventy-five year old female Medicare beneficiary with a history of hypertension and advanced arthritis who had total hip arthroplasty performed with CPT 27130. While in the recovery room, a problem was noted in the first surgery, and the patient had to go back to the operating room for another surgery, coded under CPT 27134 as a revision. The patient remained hemodynamically stable post-op, and her pain was managed with oral narcotics. The patient was discharged home the following day with home healthcare and home physical therapy.

Now click here to answer the questions: https://www.surveymonkey.com/r/ACPAAug23

Observation Committee Case Responses and Commentary from May, 2023 Cases

Provided by the Members of the ACPA Observation Committee

Case Presentation 1

A 68-year-old male with CHF, ESRD, DM2, permanent AF, prior CVA with hemiparesis, and known nonadherence to meds including insulin and warfarin presented to the emergency room after missing last hemodialysis session. He was asymptomatic. Blood pressure was 220/100; K was 6.3,INR 1.2, glucose 375, and INR 1.2.

Committee Analysis of Responses

Thank you for your responses. We received a total of 27 responses. The results from those that responded marked 85% in favor of Outpatient services with Observation services (OBS), 7.1% Outpatient status without Observation (outpt in a bed), and 3.7% each for emergency department discharge and inpatient level of care. There was a fairly uniform response regarding the effectiveness of the dialysis with the variable sub-interpretations, that a single session would resolve the members hypertension, that the additional problems outside of hypertension would require observation hospitalization, and that dialysis would permit discharge from the emergency department. The hyperkalemia was felt not to rise to the level of requiring inpatient care, even before the dialysis. There was a fair degree of agreement among the respondents favoring observation that upgrade to an inpatient level of care might occur depending on unfolding of events, with several respondents citing duration of stay past two midnights as a factor of articular interest.

Case Presentation 2

A 75-year-old woman with DM and HTN presented at 2200 to a rural hospital with unilateral vision loss. Head CT and remainder of exam was normal. Creatinine was 2.5 from baseline of 1.3. Hospitalist is called for admission who recommends transfer to urban hospital due to lack of a neurologist at the current hospital. ED team is insisting on at least posting orders until there is acceptance for transfer from urban hospital.

Committee Analysis of Responses

Thank you for your responses. We received a total of 27 responses. The results from those that responded marked 44% in favor of direct ED to Emergency department transfer, 33.33% in favor of Outpatient status with Observation, and 22% in favor of inpatient hospitalization. each for emergency department discharge and inpatient level of care. Commentary was centered as much on operational particulars as clinical concerns. There was a fairly uniform response regarding severity, and urgency of condition, as well as need for a specialty involvement. Arguments for direct ED to ED transfer noted that it might better ensure transfer due to EMTALA, and that hospitalization might actually delay the transfer, that there was a wide differential, and that a different specialty, such as ophthalmology, might actually be the correct consulting service. An alternate perspective, again weighed towards pragmatic concerns, was that the time to acceptance and transfer ultimately could not be known or relied upon. Uncertainty of time delay in transfer was mentioned in several commentaries as a factor favoring hospitalization. Regarding hospitalization, the comments were aligned regarding the appropriateness of an observation level of care, several times citing reasonable expectation of less than two midnights.

Case Presentation 3

Following up, the hospitalist starts the admission process. An admit to inpatient status order is placed and H&P is completed with plan of care to transfer to urban hospital when next bed is available. Patient is still boarding in the ED when a bed becomes available at the urban hospital. A few hours later around 0400 am, patient is transferred from the ED directly to the urban hospital without arriving on a floor unit at the rural hospital. The case is caught in your short stay self-audit process for a review if it is appropriate for an Inpatient claim.

Committee Analysis of Responses

Thank you for your responses. We received a total of 27 responses. The results from those that responded marked 63% in favor of Admit to Inpatient with Transfer Exception, 30% in favor of Self-denial and Condition Code W2, and ED Discharge 7.41%. Some of the comments from Question 2 alluded to the rationale for observation and self-denial process as the case did not meet the two-midnight expectation. It would likely depend on the documentation and care plan documented in the H&P to see if transfer exception could be applied or self-denial is more appropriate. 

Clinical Pearl 

Short Stay Inpatient Exceptions include 

• Does not need to meet 2 Midnight rule expectation
• Inpatient Only Surgery
• Case by Case Exception
• Should meet 2 Midnight rule expectation
• AMA
• Death
• Transfer
• Hospice
• Clinical recovery earlier than anticipated

As we approach the end of Summer, we at ACPA celebrate the start of the tenure of our new Membership Engagement Champion, Dr. Anjani Mahabashya! You'll be hearing and seeing more of her over the next few months as she transitions into the role Dr. Clarissa Barnes has so expertly managed these last three years. Welcome Dr. Mahabashya!

Juliet B. Ugarte Hopkins, MD

President, ACPA

August 2023

Dear Esteemed Members of ACPA,

I am deeply honored and humbled to be elected as a member of the American College of Physicians Advisors Board of Directors in the esteemed role of Membership Engagement Champion . With your support and trust, I am eager to contribute to the growth and development of this esteemed organization, championing our shared mission of advancing healthcare excellence. 

As we stand at the forefront of a rapidly evolving healthcare landscape, my vision for the ACPA centers around three pillars: Collaboration, Innovation, and Empowerment.

1. Fostering Collaboration: I firmly believe that collaboration is the bedrock of progress. I plan to facilitate open channels of communication among our diverse members, inviting ideas, feedback, and insights from every member. By creating a space where we can freely share knowledge and experiences, we can elevate the collective expertise of our healthcare providers and drive transformative change in the healthcare industry.

2. Embracing Innovation: Technology is shaping the future of healthcare, and I am passionate about harnessing its potential to optimize our practices. I envision ACPA as a hub of innovation, offering educational resources, training, and support to help our members stay ahead in this dynamic field.

3. Empowering Healthcare Providers: ACPA plays a pivotal role in empowering healthcare providers, and I am committed to expanding our resources and offerings to cater to the diverse needs of our members. Through comprehensive education programs, mentorship opportunities, and professional development initiatives, we can equip our healthcare providers with the tools they need to excel as leaders and advocates for positive change.

Furthermore, I intend to strengthen ACPA‘s partnerships with other healthcare organizations, fostering collaborative efforts that will amplify our collective impact. By working closely with industry stakeholders, policymakers, and fellow healthcare professionals, we can advocate for health, equity, improved patient experiences, and more efficient healthcare systems.

I also believe that recognition and appreciation are essential for fostering a sense of belonging and motivation within our community. I will advocate for acknowledging the outstanding contributions of our healthcare providers and celebrating their successes. 

As we draw near to the end of this message, I want to extend my profound gratitude to my boss Dr. Robert Leschingski. His mentorship and encouragement have been transformative in providing me the confidence to embrace challenges and seek new opportunities in the dynamic world of healthcare. Additionally, I am incredibly fortunate to work alongside an exceptional team of Physician Advisors and an outstanding Utilization Management nurse team. Their unwavering commitment to patient care and dedication to excellence have been driving forces behind my continual growth and development. 

In conclusion, I am deeply committed to serving ACPA and its members with utmost dedication and passion. Together, we can embrace the challenges of the ever-changing healthcare landscape, transform obstacles into opportunities, and create a future where we, as healthcare providers, play a central role in shaping a healthier, more equitable world.

I eagerly look forward to collaborating with each of you to bring our shared vision to fruition.

Dr. Anjani Mahabashya