Hospital Discharge Appeal Rights

1
Hospital Discharge Appeal Rights

• Patti Johnson, RN, CPHQ
• Director, Review Services
• Quality Insights

2
Hospital Discharge Appeals

• Began July 2, 2007

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Beneficiaries Affected

• Traditional Medicare beneficiaries
• Medicare Advantage enrollees
• Dual eligible (Medicare Medicaid)
• Beneficiaries with Medicare as a secondary payer

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Facilities Affected

• Any hospital that provides inpatient care
• Short Term Acute Care Hospitals
• Long Term Acute Care Hospitals
• Critical Access Hospitals
• Inpatient Psychiatric Hospitals
• Inpatient Rehabilitation Hospitals

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Transfers

• If transferring to another acute care inpatient
  setting, follow-up copy of IM NOT required prior
  to leaving original hospital
• Receiving facility delivers initial copy of IM
  again after transfer into new facility

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Exclusions to Process

• Swing beds in hospitals considered lower level
  of care
• Beneficiary exhausts Part A days
• Hospital outpatients who are receiving Part B
  services

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Exclusions to Process (Continued)

• Admissions for services that Medicare never
  covers
• Outpatient departments (ED, Observation)
• Patients signing out AMA

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Issuance of Important Message (IM)

• OMB Approval 0938-0692 (CMS-R-193)
• Must issue IM within two calendar days of
  admission
• Must obtain signature of patient or
  representative and provide copy
• If beneficiary refuses to sign, date of refusal
  is noted as date of receipt
• Preadmission no more than 7 calendar days in
  advance of admission

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Issuance of Important Message (IM)

• Patient unable to sign and representative
  unavailable
• Facility must contact representative by phone,
  explain IM and note understanding on IM under
  additional information space (mail or fax notice
  same day)
• If unable to contact by phone or no return call,
  note attempts in additional information space
• Can send IM by certified mail
• Voice mail messages alone are not acceptable
• When sent by delivery, valid delivery date is
  date letter is signed or date of refusal to sign

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Delivery of Follow Up IM

• Deliver follow up IM no more than two calendar
  days before discharge
• May be either a new blank IM or a copy of the IM
  that was signed after admission
• Must obtain a date and signature on blank copy
  or date and initial on signed original IM in
  space provided
• When original IM was delivered within two
  calendar days of discharge, NO follow up copy is
  required

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Timing of Notice Delivery

• Admitted on Monday
• Given Initial IM on Wednesday
• Discharged on Friday (follow up copy of IM not
  required)

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Delivery of Follow Up IM

• Routine delivery of the follow-up IM on the day
  of discharge should be avoided
• When follow up IM is given on day of discharge,
  patients should be given at least four hours to
  consider discharge appeal
• If patients condition changes and he or she is
  not discharged, another follow up IM should be
  delivered within two calendar days of new
  discharge date

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Detailed Notice

• Must be OMB approved notice Approval Number
  0938.1019 (CMS 10066)
• Must deliver Detailed Notice no later than noon
  the day after the QIO notifies hospital of the
  Request for Appeal
• For MA Plan enrollees, the Plan must directly or
  by delegation deliver a Detailed Notice

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Request for Expedited Review

• Request for review made no later than midnight of
  the day of discharge (Expedited Review)
• QIO available seven days a week from 830 a.m.
  till 500 p.m., off hours voice mail
• QIO notifies the hospital and MA Plan of request
  for review
• Upon notification by QIO, Detailed Notice is
  delivered no later than noon of the day after the
  QIOs notification

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Skilled Nursing Facility Placement

• Discharge planning would include arrangements and
  verification of available SNF bed
• If SNF bed becomes unavailable during appeal
  process, QIO will continue appeal
• Hospital should pursue another SNF placement as
  quickly as possible
• Patient cant be held liable if SNF bed becomes
  unavailable

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QIO Process

• Upon notification by QIO, hospital must supply
  medical record, copy of IM and copy of Detailed
  Notice
• QIO is required to contact the MA Plan

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QIO Process (Continued)

• Information must be supplied no later than noon
  of the day after QIO notification
• Medical record and Detailed Notice must be
  received before review can proceed
• Facilities will be instructed at the time of
  initial call with QIO whether to overnight mail
  or fax documents

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QIO Process (Continued)

• QIO must determine if hospital delivered a valid
  IM
• Use standard IM published by CMS
• IM signed and dated by beneficiary or
  representative
• Meets notice delivery timeframes
• If invalid
• Hospital may need to re-issue IM
• QIO proceeds with review process
• QIO educates hospital retrospectively

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QIO Process (Continued)

• QIO must solicit views from the patient or
  representative
• Hospital or MA Plan must provide a copy of
  documentation that was sent to QIO, if requested
  by the patient or representative (day after
  request made)
• QIO must provide opportunity for hospital and MA
  Plan to explain why discharge is appropriate

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QIO Process (Continued)

• QIO must make decision within one calendar day
  after receiving all necessary information
• QIO will notify (telephonically) beneficiary or
  representative, hospital, and MA Plan of decision
• Telephone notification will be followed up with a
  letter

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QIO Process (Continued)

• No patient liability during timely expedited
  review
• If QIO agrees with discharge, financial liability
  for beneficiary begins at noon of the day after
  telephone notification
• If QIO disagrees with discharge, patient is not
  financially responsible
• Process would begin again when a new follow up IM
  is provided

22
QIO Process (Continued)

• If beneficiary or representative remains as
  inpatient and is dissatisfied with QIO decision,
  a reconsideration may be requested

23
QIO Reconsideration Process (Continued)

• If initial decision is reaffirmed, the date of
  liability for the beneficiary remains the same
• Request for reconsideration must be made by noon
  of the calendar day following notice of initial
  telephone determination
• QIO has three days to process reconsideration and
  notify all parties

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QIO Reconsideration Process (Continued)

• Beneficiary may request an extension up to 14
  days for the reconsideration
• Provider may not bill until reconsideration
  determination
• Untimely reconsideration request follows standard
  claims appeal process

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Untimely Requests for Review

• Untimely request beneficiary or representative
  does NOT call QIO by midnight on the day of
  discharge
• If beneficiary remains in the hospital, the QIO
  has two calendar days to complete the review
  following receipt of all requested information
• Patient not protected from liability during
  untimely appeal

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Untimely Requests for Review (Continued)

• Beneficiary no longer in the hospital
• Facility provides detailed notice and all
  information needed to QIO within 30 days of
  notification of request
• QIO has 30 calendar days after receipt of all
  necessary information to make decision
• Beneficiary can request a review within 30
  calendar days of the date of discharge or at any
  time for good cause

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Untimely Requests for Review (Continued)

• MA Plan Enrollee
• Untimely requests from an MA Plan enrollee,
  enrollee must contact the MA Plan

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Hospital Issued Notices of Noncoverage (HINNs)

• Preadmission and Admission HINN process
  unchanged
• For MA Plan enrollees preadmission and
  admission reviews are responsibility of MA Plan
• Other HINNs have been retired

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QIO Concurrence (HINN)

• Hospital determines inpatient care no longer
  needed
• Unable to obtain physician agreement
• Hospital may request QIO concurrence for either
  FFS Medicare or MA Plan enrollee Hospital
  Requested Review

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Hospital Requested Review

• Hospital Requested Review Process replaces HINN
  10
• QIO concurrence for discharge
• Revised model language
• Valid delivery required

31
Hospital Requested Review (Continued)

• Hospitals must consult with the MA Plan prior to
  issuance
• Hospitals must notify the beneficiary that QIO
  concurrence has been requested
• Follow up copy of signed IM held
• QIO decision made within two days of receipt of
  necessary information
• QIO review should not be used to settle
  disagreement between facility and MA Plan

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Hospital Requested Review (Continued)

• Hospital provides information to QIO day after
  the request is submitted to QIO
• QIO solicits views of beneficiary
• QIO notifies parties of decision telephonically
  and followed by letter
• Patient becomes liable on noon of day after QIO
  notification
• Follows same reconsideration process

33
QIO Availability for HINNs

• Accepts hospital requests for preadmission/admiss
  ion HINNs and hospital-requested review for QIO
  concurrence during regular working hours
• Performs these reviews Monday through Friday
• Only list pre-admission and admission HINNS on
  the monthly HINN log

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HINN 11

• The item or service at issue must be a
  diagnostic or therapeutic service excluded from
  coverage
• The beneficiary must require continued hospital
  inpatient care
• HINN 11 ONLY used for services when there is a
  published Medicare coverage policy (national or
  local) confirming the service is noncovered

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HINN 11 (Continued)

• HINN 11 will not automatically be reviewed by
  QIO
• QIO will only review if a complaint is received
  from a beneficiary or the Intermediary requests
  QIO review

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HINN Letter 12

• Located at www.cms.hhs.gov/bni
• Click on FFS HINNs
• To be used until the official hospital ABN is
  approved
• To be used when the QIO review outcome agrees
  with discharge and when beneficiary does not
  request QIO appeal and doesnt leave by the date
  of discharge

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Key Points

• It is extremely important to include discharge
  planning documentation in the medical record
• Help beneficiary understand the process

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Contact Information For IM

• Quality Insights of Pennsylvania
• 2601 Market Place Street, Suite 320, Harrisburg,
  PA 17110
• Phone number for IM
• 1.800.322.1914

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Important Web Sites

• www.cms.hhs.gov/bni
• Under Beneficiary Notices Initiative (BNI),
  click on Hospital Discharge Appeal Notices
• Check site often for updates
• Questions may be e-mailed to CMS at
  Weichardt_ODF_at_cms.hhs.gov
• Quality Insights Web site www.qipa.org

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Process Questions

• Patti Johnson, RN, CPHQ
• Director, Review Services
• Phone [phone], extension 7628
• E-mail pjohnson_at_wvmi.org

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QUESTIONS ??
This material was prepared by Quality Insights of
Pennsylvania, the Medicare Quality Improvement
Organization for Pennsylvania, under contract
with the Centers for Medicare Medicaid Services
(CMS), an agency of the U.S. Department of Health
and Human Services. The contents presented do not
necessarily reflect CMS policy. Publication
number 8SOW-PA-REV07.118 App. 8/14/07