Is this legal?

racingmurse320q · Jul 9, 2015

I would be interested in seeing other replies on this issue. The occasional 3:1 for a nurse in the unit happens, but daily for over half the staff seems unacceptable. It's a burnout/compassion fatigue issue for me, but legally I would like to see what, if any, implications there are. We had this conversation the other day in our unit and one of the nurses claimed that they had been reported for this not long ago.

liane90 · Jul 9, 2015

I worked for a Medicaid HMO plan, and we ran into this issue where hospitals would bill for things at the higher level of care cpt codes when it wasnt appropriate. If it was paid in error, it would be taken back. If it was determined that this was done knowingly and to cause deceit, aka fraud, they would be subjected to a formal state investigation. If found guilty, state funding and licenses are pulled.

It is not legal to commit fraud.

heron, ASN, RN · Jul 9, 2015

Isn't that what they call "upcoding"? Totally fraudulent now, but I remember seeing nursing journal articles on DRGs years ago. They basically gave instruction on how to maximize reimbursement by billing under the most expensive applicable DRG. Nothing's changed, I see.

MendedHeart · Jul 9, 2015

I'm not sure what this situation falls under because I'm sure it's very unique. There are 3 beds on the stepdown unit that are hardwired. The patient that go to these beds are usually fresh carotid endarterectomy patients. They generally stay overnight. The only reason the need the "intensive care" bed is due to the art line and a couple of vasoactive gtts that we occasional manage when trying to control BP. We do not vent, sedate or really anything else the true ICU does. I just thought it was weird to bill like the ICU. Although its higher level of care than the other patients on the floor, it's not really ICU care.

MendedHeart · Jul 9, 2015

I'm am referring to the "level of care" here

Altra, BSN, RN · Jul 9, 2015

In my experience, step-down units are considered to be critical care areas.

Is there such a thing as a different billing code unique to a stepdown level of care? I don't know the answer to that, but it's something I would want to know before suspecting that a facility is upcoding or engaging in a fraudulent or unethical practice.

MunoRN, RN · Jul 9, 2015

Medicare and insurers don't pay for an "ICU bed", or for any particular staffing. They pay for a DRG and level of complexity which takes into account workload but is not strictly defined by staffing ratios. For instance, a need for 1:1 staffing can help justify a higher complexity for billing reasons but isn't the basis of how that's defined.

Wile E Coyote, ASN, RN · Jul 9, 2015

The titrated vasoactive gtts and art line = higher acuity and thus bill like an "ICU bed" all by themselves.

MendedHeart · Jul 9, 2015

Medicare and insurers don't pay for an "ICU bed", or for any particular staffing. They pay for a DRG and level of complexity which takes into account workload but is not strictly defined by staffing ratios. For instance, a need for 1:1 staffing can help justify a higher complexity for billing reasons but isn't the basis of how that's defined.

Ok that makes sense, I guess my problem is the patient ratio then. I just don't understand how an insulin gtt which has a different level of care than the ICU beds, but the Nurse - patient ratio is the same, both 3:1 all the time.

Horseshoe, BSN, RN · Jul 9, 2015

I worked at times in a stepdown ICU with a 3:1 ratio. By definition, their patients were any critical patient who was not vented. But everything else involved in ICU care could be sent to that unit. Art lines, multiple titrated drips, etc., you name it, you could find it in stepdown as long as they were not vented. It could be completely killer to have 3 patients in that unit. If your vented patients were fairly stable, the 2:1 ICU ratio could be a much easier day.

Everyone who worked stepdown had to be "ICU certified" and could be floated to any other ICU in the hospital.