One Healthcare System’s Response to Utilization Management During Hurricanes Helene and Milton

Today I’d like to share some background about the critical role that utilization management (UM) plays during public emergencies, particularly based on our experiences during Hurricanes Helene and Milton in 2024. These storms were instrumental in reshaping BayCare’s approach to patient care and management during disasters.

When these back-to-back hurricanes struck, BayCare facilities faced unprecedented challenges. Our hospitals were flooded with patients displaced by the storm, via either choice or mandatory evacuations. One of the most pressing utilization issues was ensuring compliance with Medicare inpatient status criteria amid the chaos. For context, most Skilled Nursing Facilities (SNFs) in the Tampa Bay area, along with inpatient rehab facilities and group homes, were forced to close ahead of the storms. This left acute-care hospitals to manage patients who normally would have been cared for at lower levels, creating significant strain on already short-staffed emergency departments. Many of these facilities remained closed for days due to structural damage and staffing shortages, resulting in prolonged hospital stays and additional strain on resources.

A key challenge involved Medicare patients hospitalized in outpatient status who had a safe discharge plan, but refused to leave the hospital. After Hurricane Helene, BayCare’s utilization review (UR) leadership reached out to the Centers for Medicare & Medicaid Services (CMS) for guidance on issuing Advance Beneficiary Notices (ABNs) in these cases. CMS confirmed that ABNs could be issued for outpatient/observation patients with a safe discharge plan who chose to remain in the hospital, provided that a discharge order was in place. However, CMS advised against changing the patient’s status to inpatient. This was crucial, as approximately 40 percent of our long-stay outpatient in a bed (OPIB) patients were Medicare Fee-For-Service, and we needed to maintain compliance while managing patient safety and hospital capacity.

To facilitate effective decision-making and regulatory compliance, BayCare implemented a process that required physician advisor (PA) review for all Medicare patient encounters during emergencies. This clinical oversight helped mitigate the risk of noncompliant status changes and supported alignment with regulatory guidelines and the intent of emergency waivers.

A major decision during the crisis was limiting the use of Condition Code 44 to downgrade Medicare patients during the public emergency, particularly when safe discharge options were unavailable. Given the widespread SNF closures and limited care settings in the aftermath, the UR/PA teams evaluated appropriate patient status while remaining compliant with federal and state emergency provisions. Collaboration between the PAs and UR teams was critical in providing attending physicians with clear guidance on patient status, particularly in ensuring proper documentation to support inpatient status. For example, when a patient was admitted as an inpatient due to the storm, UR nurses worked closely with the attending physician to verify that the documentation accurately reflected the patient’s risk of further illness or injury if discharged. This process ensured that all necessary details were captured, aligning with regulatory requirements and supporting appropriate care decisions. Simply upgrading a patient’s status to inpatient without these discussions would have violated the intent of the waivers and CMS regulations.

Pediatric patients requiring ventilator support presented additional challenges. Many could not safely be discharged due to power outages and a lack of resources at home. Given the complexity of care required, inpatient admission was the best option. Regulatory waivers allowed us to make these decisions, especially when patients needed hospital-level care due to electricity-dependent medical needs.

Communication barriers and displaced team members complicated the UM process during the hurricanes. Spotty cellular service and power outages disrupted coordination between UR nurses, PAs, and attending physicians. This highlighted a key learning opportunity. Each hurricane season, we emphasize preparation for personal and family safety. However, following last year’s storms, we realized the need to improve communication within our UR/PA teams and with attending providers. Moving forward, we will be more proactive in setting expectations about how patient status will be managed in an emergency, ensuring timely discussions about inpatient status documentation to maintain compliance and facilitate appropriate care decisions.

In addition to managing patient status, a critical part of our response was confirming that Managed Medicare and Medicaid health plans adhered to state and federal public emergency waivers. These waivers relax certain authorization and policy requirements during disasters, such as the three-day SNF waiver for Medicare Fee-For-Service patients. To support our hospitals, the Florida Hospital Association (FHA) requested that commercial, Managed Medicare, and Medicaid HMO health plans provide flexibility during Hurricanes Helene and Milton. Health plans were asked to waive UM requirements, facilitating smoother transitions for affected patients.

Key waivers requested from health plans included:

1. Waiving prior authorization and concurrent review for critical services, such as skilled nursing, inpatient rehabilitation, home health, durable medical equipment, and more;
2. Waiving UM requirements that could delay patient care;
3. Extending timeframes for submitting claims and appeal; and
4. Waiving out-of-network cost-sharing for displaced patients.

The FHA advocated for these waivers to be implemented statewide, helping all facilities respond effectively to the emergency, regardless of their proximity to the storm’s impact zone. Unfortunately, not all healthcare plans complied with the intent of the emergency waivers, and that’s a story for another time.

Looking ahead, BayCare is developing a comprehensive Hurricane Playbook that will establish standardized procedures for managing patient care, including UM and status management, during public emergencies. This playbook is designed to improve proactive communication, ensure regulatory compliance, and foster patient-centered decision-making across all levels of care. By strengthening these processes, we aim to enhance our response to future disasters and optimize patient outcomes.

The lessons learned from Hurricanes Helene and Milton emphasize the crucial role of UM in safeguarding patient care and maintaining compliance during disasters. By applying these experiences, BayCare is committed to strengthening emergency response protocols and improving patient outcomes in future public emergencies.

Don’t forget to join us for NPAC 2025, Healthcare Heroes: Physician Advisors Reaching New Heights, from April 7-10 at the Chicago Marriott Downtown Magnificent Mile. The event will feature expert speakers, over 40 CME credits, and premier networking opportunities. You can still sign up to attend virtually through the ACPA website. It’s a chance to learn, connect, and lead the future of PAs!