When people come to the emergency department (ED) without a genuine medical reason, hospitals may want to quickly admit them as inpatients and give them a notice that explains they will have to pay for the hospital care because it’s not covered, experts say. It’s a way to manage social admissions/custodial care hospitalizations.
“It’s a little bit of a controversial option, but it’s out there in the ether and in theory it’s a possibility,” said Juliet B. Ugarte Hopkins, M.D., physician advisor at Phoenix Medical Management in Arizona. Hospitals would use the Hospital-Issued Notice of Noncoverage (HINN) with Medicare fee-for-service patients and a comparable form with patients who have commercial insurance, she said at a July 27 webinar sponsored by RACmonitor.com.
Hospitals have other options for addressing social admissions/custodial care patients, who are a heartbreaking thorn in their side and a revenue and compliance challenge. Two of them—keeping custodial-care patients in the ED or placing them in observation—have their own risks, including mistakes around patient notices and billing limitations. False claims lawsuits are an outside possibility. For example, San Mateo Medical Center and San Mateo County in California agreed to pay $11.4 million in 2021 to settle false claims allegations in connection with billing Medicare for social admissions.[1]
One way or another, something has to give, because custodial care patients take up beds that are needed by sick people, Ugarte Hopkins said.
The common theme of social admissions/custodial care is the lack of medical necessity for hospital care. For example, a family brings in the elderly mother they have cared for over the past two years while her daughter has worked remotely, but now she’s returning to the office. “She’s looking for placement in a nursing home,” Ugarte Hopkins said. “It’s one of these situations where they don’t feel like they can manage her anymore, so they bring her to the hospital.” Another example would be a patient who was discharged from the hospital to an assisted living facility (ALF) and two days later he’s back. “The patient won’t leave his bed,” Ugarte Hopkins said. “The facility doesn’t know what to do.” Because the patient requires help with activities of daily living, the ALF’s manager calls 911. “Many times, nothing medical is found and there needs to be a different placement situation,” she noted.
Social admissions affect hospitals in a “multifactorial” way, Ugarte Hopkins said. Physicians and advanced practice providers are trained to manage the medical needs of patients and aren’t “prepared to address many of the social or custodial things that happen,” she noted. They’re required to continue rounding daily, examining the patient and writing notes. While it can be conveyed that the physician is only doing a cursory review, the performative rounding takes up the physician’s time and “contributes to burnout,” Ugarte Hopkins said. At the same time, utilization reviewers and case managers feel the pressure to get patients out of the hospital, and “part of that is being the bad guy. You’re giving information to patients and the family they don’t want to hear. Then there’s uncertainty about what can be done and said based on the payer.”
