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

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

4. 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

5. 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

6. 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

7. Exclusions to Process (Continued) • Admissions for services that Medicare never covers • Outpatient departments (ED, Observation) • Patients signing out AMA

8. 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

9. 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

10. 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

11. Timing of Notice Delivery • Admitted on Monday • Given Initial IM on Wednesday • Discharged on Friday (follow up copy of IM not required)

12. 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 patient’s condition changes and he or she is not discharged, another follow up IM should be delivered within two calendar days of new discharge date

13. 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

14. 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 8:30 a.m. till 5:00 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 QIO’s notification

15. 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 can’t be held liable if SNF bed becomes unavailable

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

24. 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

25. 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

26. 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

27. Untimely Requests for Review (Continued) • MA Plan Enrollee – • Untimely requests from an MA Plan enrollee, enrollee must contact the MA Plan

28. 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

29. 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

30. 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

32. 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/admission 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

34. 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

35. 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

36. 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 doesn’t leave by the date of discharge

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

38. 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

39. 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@cms.hhs.gov • Quality Insights’ Web site: www.qipa.org

40. Process Questions • Patti Johnson, RN, CPHQ • Director, Review Services • Phone: 1.877.346.6180, extension 7628 • E-mail: pjohnson@wvmi.org

41. 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