Precertification Requirement Delays Discharge After Stroke

Pauline Anderson

April 28, 2015

WASHINGTON, DC — Requiring precertification from private insurance companies delays hospital discharge of stroke patients to a nursing facility or rehabilitation, a new study shows.

Researchers found that patients who required insurance precertification had an average delay in discharge of 1.5 days compared with 0.8 day for those not requiring such precertification, a statistically significant difference of 0.7 day.

"From this study, we feel that the precertification process of private insurance companies is associated with delays in discharge to posthospitalization rehabilitation," said Andrew L. Smith, neurology resident, University Hospitals Case Medical Center (UHCMC), Cleveland, Ohio.

"Known cofactors that could possibly explain this difference were analyzed and were not different between the two groups," he added.

Dr Smith presented the study results here during the American Academy of Neurology (AAN) 67th Annual Meeting.

Running Out of Money

Precertification requires a skilled nursing or acute inpatient rehabilitation facility to apply for approval from an insurer before a patient can be sent to that facility. Medicare does not require precertification; it has published guidelines that outline what it will and will not pay for regarding posthospital rehabilitation.

The cost for a hospitalization for stroke is estimated to be about $20,000. Since almost 800,000 strokes occur every year in the United States, this adds up to an annual bill to the healthcare system of $16 billion, the researchers point out.

"The reason this becomes increasingly important is simply that under current legislation and current spending patterns, the Medicare Fund is projected to run out of money in 2030," said Dr Smith.

As a result, reforms are under way to increase the quality of care and maintain the same cost, or keep the same quality of the care while reducing costs, he said.

In the area of stroke, the focus is on reducing delays in discharge. Studies have uncovered several factors associated with prolonging hospitalizations, including age, sex, marital status, insurance type, stroke severity, and delays in arranging disposition.

In one study cited by Dr Smith, about half the patients had a delayed discharge because of issues related to arranging patient disposition. This, he said, broke down into three categories: delayed planning by hospital staff for disposition, finding a facility that had the capacity to take the patient, and the logistics of getting insurance approval for rehab.

A factor that appeared to delay discharge was the precertification requirement. "A goal of the current study was to determine whether or not this precertification process actually does delay discharge," said Dr Smith.

Chart Review

The study was conducted at UHCMC in Cleveland, a nonprofit tertiary hospital with 771 beds and over 45,000 admissions per year. The hospital is a Joint Commission–certified Comprehensive Stroke Center.

Researchers carried out a retrospective chart review of adult patients who were admitted with a primary diagnosis of any stroke type from February 2013 to January 2014, were evaluated by a physical and occupational therapist, and were recommended to be discharged to a skilled nursing facility or acute inpatient rehab institution.

Of the 1007 patients who were screened, 289 met study inclusion criteria; 118 required insurance precertification and 171 did not.

Dr Smith and his colleagues performed a multiple regression analysis to determine the effects of age, marital status, National Institutes of Health Stroke Scale (NIHSS), length of stay, and number of days awaiting precertification on the requirement for precertification. They determined that the only factor that varied significantly between the two groups was the delay of discharge variable.

Length of Stay

Although the difference in length of stay was similar to the difference in delay in discharge between the two groups (7.2 days for precertification requirement vs 6.5 days for no precertification requirement), it didn't reach statistical significance (P = .25). "This was largely because of the greater range of lengths of stay," said Dr Smith.

While previous research suggested that delays in disposition may be due in part to delayed planning by hospital staff, the current chart review tried to control for that by ensuring decisions were made by the same staff, said Dr Smith. "This study assumes that the staff was performing essentially at the same caliber throughout the year."

The delay could be corrected by having insurance companies conform to Medicare standard criteria for coverage, which would eliminate the need for the precertification process, or through an internal hospital audit.

The audit route, which Dr Smith thinks is more likely, could identify delays in discharge among the various insurance companies. "If there's a company that's truly an outlier that is significantly taking time to do this precertification process, you could potentially use that in future contract negotiations."

Weekend Effect

Session co-chair, Jin-Moo Lee, MD, PhD, director, Cerebrovascular Disease Section, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, queried Dr Smith about the "weekend effect", based on previous observations that stroke care is less rapid and in some cases less effective on weekends.

According to Dr Smith, his study did not investigate the weekend effect, although it's something he and his colleagues will be looking at in the future.

This effect "is a major reason for delay" in discharging stroke patients, Dr Lee told Medscape Medical News after the session. "Unfortunately, all insurance companies are closed over the weekend and so precertification is not possible until Monday," he said.

However, this is likely not the only reason for delayed discharges, said Dr Lee. "Often, insurance companies will deny referrals into other facilities, which forces hospital to find other alternatives. This can also be a reason for delay."

Although hospitals certainly lose money every year because of this delay, Dr Lee said he's unsure of the economic impact of delays caused by the precertification requirement.

The researchers have disclosed no relevant financial relationships.

American Academy of Neurology (AAN) 67th Annual Meeting. Abstract S5.004. Presented April 21, 2015.

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