Notification of Hospital Discharge Appeal Rights Provider and QIO Responsibilities

1
Notification of Hospital Discharge Appeal Rights
Provider and QIO Responsibilities

• Susan M. Cannon, RN, CPC-A
• AQAF

This material is distributed by AQAF, the
Medicare Quality Improvement Organization for
Alabama, under contract with the Centers for
Medicare Medicaid Services (CMS), an agency of
the U.S. Department of Health and Human Services.
8SOW-AL-GEN08-16
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What We Will Cover

• Important Message from Medicare (IM)
• Provider and Quality Improvement Organization
  (QIO) responsibilities and interactions

3
Important Message from Medicare

• Standardized appeal and liability info
• All Medicare patients and Medicare Advantage (MA)
  plan enrollees
• All inpatient hospitals

4
Definitions

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

5
All Medicare Beneficiaries

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

6
Exclusions

• Non-covered stay, benefit exhaustion
• Change from inpatient to outpatient (use of
  Condition Code 44, MedLearn Matters article,
  SE0622)
• Transfer from one inpatient hospital setting to
  another inpatient hospital setting (includes
  short-term acute care to long-term acute care)

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IM Not Used For

• Religious, non-medical health care institutions
• Swing beds
• Outpatient departments (such as ED,
  observation-receiving Part B services)
• If patient is transferring to unit that bills
  with the same provider number-considered
  transfer, not discharge for Medicare
  purposes-deliver IM within 2 days of d/c

8
Exclusions, continued

• Hospital patients who elect hospice coverage
  would not receive the follow-up copy of the IM,
  IF the hospice election occurs prior to discharge
  from acute care
• If Preadmission/Admission HINN or HRR
  appropriate-covered later in presentation

9
Timing of Initial Copy

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

10
Timing of Follow-Up Copy

• As soon as possible when discharge is planned,
  but no more than two days before
• Avoid routine delivery of follow-up IM on day of
  discharge or routinely scheduled days during week
  such as Mon-Wed-Fri
• At least four hours prior to discharge

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Timing of Follow-Up Copy

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

12
Timing of Follow-Up Copy

• Initial copy given on 7th (during preadmission
  visit)
• Admitted as inpatient on 10th
• Discharged on 11th IM given
• follow-up copy must be given if more than two
  calendar days elapsed since initial copy delivered

13
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

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Communicate the Plan

• Inform patients of transfer and discharge plans
• Involve team if there are questions about transfer

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Valid Delivery Requirements

• Standardized Notice (CMS-R-193) found on CMS
  Beneficiary Notices Initiative (BNI) Website
• Notice cant be modified, except as specifically
  allowed by CMS instructions.
• Signed and dated, understood by patient or
  acceptable representative

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Valid Delivery Requirements

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

17
Delivery to Representatives

• For incompetent patient, use state guidelines to
  identify responsible person
• In-person delivery of IM preferred

18
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

19
Telephone Delivery to a Representative

• Voice mail not acceptable
• Provide complete explanation
• Mail or fax notice on same day

20
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

21
QIO Availability for Discharge Appeals

• Accepts patient requests for discharge appeals 24
  hours/day
• Performs appeal reviews seven days/week
• Answering machine or voice mail after hours

22
Timely Patient Request for Appeal

• No later than midnight on the day of planned
  discharge in writing or by telephone
• No patient liability during timely expedited
  appeal

23
Timely Patient Request

• QIO notifies hospital or MA plan ASAP
• Hospital or MA plan issues Detailed Notice
  (CMS-10066) to patient ASAP but not later than
  noon of next day

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Detailed Notice

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

25
Timely Patient Request

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

26
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 two days of discharge
• Must have available SNF bed to assign liability

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QIO Performs Review

• Contacts involved parties for comments
• Makes determination within one calendar day
• Notifies facility, patient or representative,
  attending physician and MA plan
• Phone call followed up in writing

28
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 MA plan

29
Untimely Request

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

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Untimely Request

• 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

31
Untimely Request

• QIO makes determination and notifies hospital,
  patient and attending physician within two
  calendar days if the patient remains in the
  hospital.
• Patient not protected from liability during
  untimely appeal

32
Untimely Request

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

33
Untimely Request

• QIO will contact the facility and request
  information including medical record, IMs and
  detailed notice.
• The QIO will make its determination and notify
  all parties of its determination within 30 days
  after receipt of the request and pertinent
  information.

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Liability After Untimely Request

• Patient is liable for any charges incurred after
  the day of discharge or as otherwise stated by
  the QIO.

35
Patient asks for QIO review

• HINN 12 can be issued as soon as the hospital
  receives the QIOs determination that the
  discharge was appropriate however patient
  liability cannot begin before noon of the day
  after the QIO decision is received.

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Patient does not ask for a QIO review

• HINN 12 should be delivered the morning following
  the discharge date.

37
QIO Availability for HINNs and HRRs

• Accepts beneficiary requests for
  Preadmission/Admission HINNs and
  Hospital-Requested Review for QIO concurrence
  during regular working hours
• Performs these reviews Monday through Friday

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Reconsiderations

• Original Medicare Beneficiaries
• Timely request by inpatient by noon of day
  following QIO notification of initial decision
• QIO notifies all parties of determination within
  72 hrs if patient remains hospitalized
• Provider may not bill until reconsideration
  determination made and parties notified.

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Reconsiderations

• MA Plan Enrollees
• If still an inpatient in the hospital-QIO does
  reconsideration review with recommended
  determination and notification within 72 hrs
• If no longer an inpatient-standard or expedited
  plan appeal process

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HINN 11

• Used for noncovered items or services provided
  during an otherwise covered stay.

41
Preadmission/Admission HINNs

• Used prior to an entirely noncovered stay
• Timeframes, liability and general appeal process
  are not changed.
• IM not appropriate unless later admitted to
  inpatient status

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Preadmission/Admission HINNs

• This notice can be found on the Beneficiary
  Notices Initiative website.
• Revised model language in Medicare Claims
  Processing Manual, Chapter 30, 240.6 exhibit 4

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Hospital-Requested Review

• Hospital determines that a Medicare beneficiary
  or MA plan enrollee no longer needs inpatient
  care but is unable to obtain the agreement of the
  physician.
• Revised notice-Medicare Claims Processing Manual,
  Chapter 30, section 225-Exhibit 3
• Valid delivery required

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Hospital-Requested Review

• Hospital can request for Medicare beneficiary and
  for MA plan enrollee
• Hospital provides information to QIO by close of
  business on first full working day immediately
  following the day the hospital submits the
  request for review.
• QIO makes determination within two working days

45
Hospital-Requested Review

• Patient becomes liable on noon of day after QIO
  notification if QIO agrees that discharge is
  appropriate
• QIO informs patient/rep of appeal rights

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Reconsideration

• The reconsideration procedures for
  preadmission/admission HINNs and for hospital-
  requested expedited reviews are the same as for
  expedited discharge appeal.

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Information for Providers

• www.cms.hhs.gov/BNI
• Under Beneficiary Notices Initiative (BNI), go
  to link for Hospital Discharge Appeal Notices
• Check site often for updates
• You may submit questions to Weichardt_ODF_at_cms.hhs.
  gov