Notification of Hospital Discharge Appeal Rights Provider and

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. 8 SOW-AL-GEN— 08 -16

What We Will Cover § Important Message from Medicare (IM) § Provider and Quality Improvement Organization (QIO) responsibilities and interactions 2

Important Message from Medicare § Standardized appeal and liability info § All Medicare patients and Medicare Advantage (MA) plan enrollees § All inpatient hospitals 3

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 4

All Medicare Beneficiaries § Original Medicare and Medicare Advantage Plan enrollees § Dual Eligible Medicare and Medicaid § Medicare Secondary Payer 5

Exclusions • Non-covered stay, benefit exhaustion • Change from inpatient to outpatient (use of Condition Code 44, Med. Learn Matters article, SE 0622) • Transfer from one inpatient hospital setting to another inpatient hospital setting (includes short-term acute care to long-term acute care) 6

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 7

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 8

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 9

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 10

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 11

Timing of Follow-Up Copy § Initial copy given on 7 th (during preadmission visit) § Admitted as inpatient on 10 th § Discharged on 11 th – IM given § follow-up copy must be given if more than two calendar days elapsed since initial copy delivered 12

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 13

Communicate the Plan § Inform patients of transfer and discharge plans § Involve team if there are questions about transfer 14

Valid Delivery Requirements § Standardized Notice (CMS-R-193) found on CMS Beneficiary Notices Initiative (BNI) Website § Notice can’t be modified, except as specifically allowed by CMS instructions. § Signed and dated, understood by patient or acceptable representative 15

Valid Delivery Requirements § Within mandated timeframes § Copy for patient; copy for record § If refuses, note date of refusal as date of receipt 16

Delivery to Representatives § For incompetent patient, use state guidelines to identify responsible person § In-person delivery of IM preferred 17

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 18

Telephone Delivery to a Representative § Voice mail not acceptable § Provide complete explanation § Mail or fax notice on same day 19

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 20

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 21

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 22

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 23

Detailed Notice § Must be OMB approved notice Approval No. 0938 -1019 § Standardized notice containing specific information 24

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 25

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 26

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 27

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 28

Untimely Request § Original Medicare beneficiary contacts QIO for untimely appeal § MA plan enrollee contacts MA plan with untimely request for discharge appeal 29

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 30

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 31

Untimely Request § If patient leaves facility, can request appeal within 30 calendar days § Can request appeal at any time for good cause 32

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. 33

Liability After Untimely Request § Patient is liable for any charges incurred after the day of discharge or as otherwise stated by the QIO. 34

Patient asks for QIO review § HINN 12 can be issued as soon as the hospital receives the QIO’s determination that the discharge was appropriate; however patient liability cannot begin before noon of the day after the QIO decision is received. 35

Patient does not ask for a QIO review § HINN 12 should be delivered the morning following the discharge date. 36

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 37

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. 38

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 39

HINN 11 § Used for noncovered items or services provided during an otherwise covered stay. 40

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 41

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 42

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 43

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 44

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 45

Reconsideration § The reconsideration procedures for preadmission/admission HINNs and for hospital- requested expedited reviews are the same as for expedited discharge appeal. 46

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@cms. hhs. gov 47