Notification of Hospital Discharge Appeal Rights and Hospital Issued Notices of Noncoverage (HINN)

1
(No Transcript)
2
Notification of Hospital Discharge Appeal
RightsandHospital Issued Notices of Noncoverage
(HINN)

• Conni Brandt, RN, BSN, CPHQ
• Vice President, Review Services
• MetaStar, Inc.
• December 6, 2011

3
Objectives

• Review MetaStars Mission and Vision
• Describe the Quality Improvement Program
• Review the Important Message from Medicare (IM)
• Review Hospital Issued Notices of Noncoverage
• Discuss Provider and Quality Improvement
  Organization (QIO) responsibilities

4
MetaStar

• Independent, non-profit, based in Madison
• 38 years of service
• WisPRO, WIPRO, and MetaStar
• Mission to effect positive change in the
  quality, efficiency and effectiveness of health
  care
• Vision to be the leading independent resource
  for improving health care quality and cost
  effectiveness.

5
MetaStars Contracts

• Medicare Quality Improvement Organization for
  Wisconsin
• Medicaid External Quality Review Organization
• Wisconsin Health Information Technology Extension
  Center (WHITEC)
• HEDIS compliance audits for health plans
• Independent medical review

6
MetaStars Customers

• Centers for Medicare Medicaid Services (CMS)
• Office of the National Coordinator for Health IT
• WI Department of Health Services

• Medicare Beneficiaries
• Hospitals
• Practitioners / Clinics
• Skilled Nursing Facilities
• Home Health Agencies
• Hospice providers
• Medicare Health Plans

7
Quality Improvement Organization (QIO)

• National network of 43 organizations responsible
  for each U.S. state and territory under the
  direction of CMS
• QIO improvement initiatives support the National
  Quality Strategy
• Six priorities safer care, coordinated care,
  person- and family-centered care, preventive
  care, community health, making care more
  affordable

8
Four QIO Program Aims

• Make Care Beneficiary and Family Centered
• Improve Individual Patient Care
• Integrate Care for Populations
• Improve Health for Populations and Communities

8
9
Beneficiary and Family Centered Care

• Review Medicare beneficiarys quality of care
  complaints
• Review hospital discharge and service termination
  decisions
• Provide technical assistance for Hospital Quality
  Reporting

10
Beneficiary and Family Centered Care National
Coordinating Center

• To improve customer service by efficiently and
  effectively handling the intake process for
  beneficiaries potential quality of care concerns

11
Important Message from Medicare (IM)

• As of July 2, 2007, inpatients subject to new
  notice requirements before discharge

12
Revisions to Notices of Noncoverage
Former Current
Preadmission/Admission Revised Preadmission/Admission
HINN 8 Discontinued 7/1/2005
HINNs 2-7 and 9 Discontinued 7/1/2007
NODMAR Discontinued 7/1/2007
IM
HINN 10 HRR
HINN 11 HINN 11
HINN 12

13
Important Message from Medicare

• Standardized appeal and liability info
• All inpatient hospitals

14
Definitions

• Hospital includes all inpatient facilities
  except religious non-medical health care
  institutions
• Discharge a formal release of a patient from
  inpatient hospital level of care

15
All Medicare Beneficiaries

• Original Medicare and Medicare Health Plan
  enrollees
• Dual Eligible Medicare and Medicaid
• Medicare Secondary Payer

16
Exclusions

• Non-covered stay due to benefit exhaustion
• Change from inpatient to outpatient
• ABN or ABN-type notice appropriate for these
  situations

17
IM Not Used For

• Swing beds
• Outpatient / observation level of care
• Outpatient departments (Emergency Department)

18
Timing of Initial Copy

• Within 2 days of inpatient admission or
• During pre-registration visit, but not more than
  7 calendar days prior to admission

19
Timing of Follow-Up Copy

• As soon as possible when discharge is planned,
  but no more than 2 days before
• Avoid routine delivery of follow-up IM on day of
  discharge
• At least 4 hours prior to discharge

20
Timing of Follow-Up Copy

• Not required if initial copy given within 2
  calendar days of discharge
• Example
• Patient admitted on Monday
• Given initial IM on Wednesday
• Discharged on Friday

21
Inpatient to Inpatient Transfers

• If transferring to another acute, inpatient care
  setting, follow-up copy of IM not required
• Receiving facility (not receiving unit within
  same facility) delivers initial copy of IM again
  after transfer to a new facility

22
Valid Delivery Requirements

• Standardized Notice (CMS-R-193) found on CMS
  Beneficiary Notices Initiative (BNI) Website
  (www.cms.gov/bni)
• Notice cant be modified
• Signed and dated, understood by patient or
  acceptable representative

23
Valid Delivery Requirements

• Within mandated timeframes
• Copy for patient copy for record
• If refuses, note date of refusal as date of
  receipt

24
Delivery to Representatives

• For incompetent patient, use state guidelines to
  identify responsible person
• In-person delivery of IM preferred
• Phone delivery is an option, when necessary

25
Delivery to a Representative

• Hospital employee would be considered to have a
  conflict of interest for liability
• Valid delivery to patient or representative
  required before liability can be assigned

26
Telephone Delivery to a Representative

• Voice mail not acceptable
• Provide complete explanation including appeal
  rights and QIO phone number
• Mail or fax notice on same day

27
Telephone Delivery to a Representative

• Document all contacts in record
• If unable to reach representative, send by
  delivery that requires signature
• Date of delivery or date of refusal is date of
  notification

28
QIO Availability for Discharge Appeals

• Accepts patient requests for discharge appeals 24
  hours/day
• Performs appeal reviews 7 days/week
• Answering machine or voice mail after hours
• Subcontract with HealthInsight, another QIO, for
  non-business days

29
Timely Patient Request for Appeal

• Before midnight on the day of planned discharge
• No patient liability during timely expedited
  appeal

30
Timely Patient Request

• QIO notifies hospital or Medicare health plan
  ASAP
• Hospital or Medicare health plan issues Detailed
  Notice (CMS-10066) to patient by noon of next day

31
Detailed Notice

• Must be OMB approved notice Approval No.
  0938-1019
• Standardized notice containing specific patient
  information

32
Timely Patient Request

• By noon of next calendar day, hospital or
  Medicare health plan provides any and all
  information QIO needs to make determination
• Upon request, hospital or Medicare health plan
  provides documentation to patient by next
  calendar day

33
Timely Patient Request

• QIO determines Valid Notice of IM and Detailed
  Notice
• Skilled nursing facility (SNF) placement
  coordinated with delivery of follow-up copy of IM
  within 2 days of discharge
• Must have available SNF bed to assign liability

34
QIO Performs Review

• Contacts involved parties for comments
• Makes determination within 1 calendar day
• Notifies facility, patient or representative,
  attending physician and Medicare health plan
• Phone call followed up with a letter

35
Liability After Timely Request

• If QIO agrees with discharge, patient liability
  begins at noon of day after QIO notification
• If QIO disagrees with discharge, the stay
  continues to be covered by Medicare or the
  Medicare health plan

36
HINN 12

• Noncovered continued stay notice
• Original Medicare beneficiaries only
• Appeal requested and QIO agrees with discharge,
  issue on day liability begins

37
Untimely Requests

• Original Medicare beneficiary contacts QIO for
  untimely appeal
• Medicare health plan enrollee contacts Medicare
  health plan with untimely request for discharge
  appeal

38
Untimely Appeal

• QIO contacts hospital, patient and attending
  physician
• Facility provides Detailed Notice to patient
  information to QIO by noon of day after being
  contacted by the QIO

39
Untimely Requests

• QIO makes determination and notifies hospital,
  patient and attending physician within 2 calendar
  days
• Patient not protected from liability during
  untimely appeal

40
Untimely Requests

• If patient leaves facility, can request appeal
  within 30 calendar days
• Can request appeal at any time for good cause

41
Untimely Requests

• Facility provides Detailed Notice to patient and
  all information needed to the QIO within 30 days
  of notification of request
• QIO notifies parties within 30 days of receiving
  all information

42
No Appeal Requested

• For Original Medicare provider issues a liability
  notice (Section 1879 of the SSA) HINN 12
• Liability begins day after planned date of
  discharge

43
Reconsiderations

• Timely request by inpatient noon of day
  following QIO notification
• Provider may not bill until reconsideration
  determination
• Untimely recon request follows standard claims
  appeal process

44
QIO Availability for HINNs

• Accepts requests for appeal of
  Preadmission/admission HINN and
  Hospital-Requested Review for QIO concurrence
  during regular business hours
• Performs review during regular business hours

45
Preadmission/Admission HINNs

• Original Medicare beneficiaries
• Not used for Medicare health plan enrollees
• Revised model language
• Same valid delivery requirements as for IM
• Same reconsideration process

46
Preadmission/Admission HINNs

• Timeframes and liability protections unchanged
• IM not appropriate unless later admitted to
  inpatient status

47
Preadmission HINNs

• Issue prior to admission
• Attending physician does not have to agree with
  issuance
• Liability customary charges for all services
  furnished during the stay, except for those
  services for which you are eligible under Part B

48
Admission HINN

• Issued when entire admission is noncovered
• Attending physician does not have to agree with
  issuance

49
Admission HINN

• Liability
• Issued no later than 3 p.m. on the date of
  admission customary charges for all services
  furnished after receipt of this hospital notice,
  except for those services for which you are
  eligible under Part B
• Issued after 3 p.m. on the day of admission
  customary charges for all services furnished on
  the day following the day of receipt of this
  notice, except for those services for which you
  are eligible to receive payment under Part B

50
Hospital-Requested Review

• QIO concurrence for discharge
• Revised model language
• Valid delivery required

51
Hospital-Requested Review

• Hospital can request for Medicare beneficiary and
  for Medicare health plan enrollee
• Hospital provides information to QIO
• QIO makes determination within 2 business days

52
Hospital-Requested Review

• Patient becomes liable on noon of day after QIO
  notification
• Hold IM associated with planned discharge
• Follows same reconsideration process

53
HINN 11

• Noncovered Service(s) during Covered Stay
• Effective September 18, 2006
• Only original Medicare beneficiaries
• Must meet basic delivery standards of other HINNs

54
HINN 11

• The item or service at issue must be a diagnostic
  or therapeutic service excluded from coverage as
  medically unnecessary, and
• The beneficiary must require continued hospital
  inpatient care
• No period to wait before becoming effective

55
Resources for Providers

• www.cms.hhs.gov/BNI
• Under Beneficiary Notices Initiative (BNI), go
  to link for
• Hospital Discharge Appeal Notices
• FFS HINNS
• Check site often for updates

56
www.cms.gov/bni
57
MetaStar

• 1-800-362-2320, ext. 8276
• Monday through Friday
• 800 to 430
• HealthInsight / subcontracting QIO
• Non-business day coverage
• 1-800-748-6773
• www.metastar.com

58
Notices of Medicare Non-coverage
59

• Questions?

60
Contact Information

• MetaStar, Inc.
• 2909 Landmark Place
• Madison, WI 53713
• Conni Brandt, RN, BSN, CPHQ
• [phone] or [phone], ext. 8209
• cbrandt_at_metastar.com
• www.metastar.com
• This material was prepared by MetaStar, the
  Medicare Quality Improvement Organization for
  Wisconsin, 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.  8SOW-WI-BENP-
  08-01.