QIO 9th SOW Hospital Issued Notices

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QIO 9th SOWHospital Issued Notices

• January 2009

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WVMI/Quality Insights

• West Virginia Medical Institute (WVMI)
• West Virginia QIO
• Quality Insights of Pennsylvania
• Pennsylvania QIO
• Quality Insights of Delaware
• Delaware QIO

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Tri-State Approach

• WVMI Quality Insights work as a team in our
  9th SOW Beneficiary Protection activities.

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Objectives of Presentation

• Discuss Notice types why given
• Discuss delivery timing
• Discuss related documentation
• Provide informational links

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Why Notices Given

• Each hospital is required by Conditions of
  Participation to have a Utilization Review
  program to ensure that only medically necessary
  services are provided in their facility.
• http//edocket.access.gpo.gov/cfr_2004/octqtr/pdf/
  42cfr482.30.pdf

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Notices

• In order to bill a Medicare beneficiary,
  providers must properly notify the beneficiary of
  potentially non-covered services and outline
  appeal rights, thus notices are given.

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Informational Link for Notices

• Beneficiary Notices http//www.cms.hhs.gov/bni/
• Links for todays discussion
• FFS HINN
• http//www.cms.hhs.gov/BNI/05_HINNs.aspTopOfPage
• Hospital Discharge Appeal Notices
• http//www.cms.hhs.gov/BNI/12_HospitalDischargeApp
  ealNotices.aspTopOfPage

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QIO Reviewed Notice Types

• Previously
• Admission HINN
• Preadmission HINN
• Important Message
• Continued Stay
• Acute to Swing

• Current
• Admission Same
• Preadmission Same
• IM/Continued Stay merged into new process

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Notices Not QIO Reviewed

• FFS HINN lists
• HINN 11
• These are used for non-covered services
  (medically unnecessary) based on published
  Medicare coverage policy (national or local).
• Primary oversight is by Intermediaries, not QIOs

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Preadmission/Admission HINN

• Location of Notice
• Timing for Delivery
• Documentation Related to Delivery

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Links for Notice Types

• Admission/Preadmission
• http//www.cms.hhs.gov/BNI/05_HINNs.aspTopOfPage
• The Preadmission/Admission HINN, used prior to an
  entirely non-covered stay, replaces HINNs 1 and
  9.

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Timing Admission/Preadmission

• Preadmission Self-explanatory
• (Beneficiary is liable, if admitted, for
  customary charges)
• Admission (Timing of delivery changes liability)
• Notices given no later than 3 p.m. date of
  admission
• (Beneficiary liable for customary charges after
  receipt of notice...)
• Notices given after 3 p.m. the day of admission
• (Beneficiary liable for customary charges ...on
  day following receipt of this notice)

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IM Notices

• Location of Notices
• Timing of Delivery
• Documentation
• Appeal Process

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Links for Notice Types

• IM and subsequent notification
• http//www.cms.hhs.gov/BNI/12_HospitalDischargeApp
  ealNotices.aspTopOfPage
• HINN 12
• http//www.cms.hhs.gov/BNI/Downloads/PreadmissionA
  dmissionHINN.pdf

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Timing-IM Notices

• Hospitals must issue the IM within 2 calendar
  days of admission, must obtain the signature of
  the beneficiary or his/her representative and
  provide a copy at that time.
• Hospitals also will deliver a copy of the signed
  notice as far in advance of discharge as
  possible, but not more than 2 calendar days
  before discharge.

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Documentation Requirements

• Regardless of the competency of a beneficiary, if
  the hospital is unable to personally deliver a
  notice to a representative, then the hospital
  should telephone the representative to advise him
  or her of the beneficiarys rights as a hospital
  patient, including the right to appeal a
  discharge decision.
• The information provided should include the
  following at a minimum
• The name and telephone number of a contact at the
  hospital
• The beneficiarys planned discharge date, and the
  date when the beneficiarys liability begins
• The beneficiarys rights as a hospital patient,
  including the right to appeal a discharge
  decision
• How to get a copy of a detailed notice describing
  why the hospital and physician believe the
  beneficiary is ready to be discharged
• A description of the steps for filing an appeal
• When (by what time/date) the appeal must be filed
  to take advantage of the liability protections
• The entity required to receive the appeal,
  including any applicable name, address, telephone
  number, fax number or other method of
  communication the entity requires in order to
  receive the appeal in a timely fashion
• Direction to the 1-800-MEDICARE number for
  additional assistance to the representative in
  further explaining and filing the appeal

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Expedited Appeal?

• If Beneficiary requests an Expedited Appeal,
  then
• Detailed notice is required
• http//www.cms.hhs.gov/BNI/12_HospitalDischargeApp
  ealNotices.aspTopOfPage

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No Appeal

• If Beneficiary does not appeal by midnight on the
  day of discharge, hospital should use HINN 12

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Hospital Requested Review

• Used for cases where attending and UR Committee
  differ

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Informational Sites

• Web site for
• The West Virginia Medical Institute
• www.qiwv.org

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Informational Links

• http//www.cms.hhs.gov/MLNMattersArticles/02_Searc
  h.aspTopOfPage
• http//www.hhs.gov/omha/
• http//www.cms.hhs.gov/BNI/12_HospitalDischargeApp
  ealNotices.asp

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Contacts 304.346.9864

• Beneficiary Protection
• Heather Poe, ext. 4274
• hpoe_at_wvmi.org
• Cathy Bowles Browning, ext. 4256
• cbowles_at_wvmi.org

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• Questions?

This material was prepared by West Virginia
Medical Institute, the Medicare Quality
Improvement Organization for West Virginia, 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.
9SOW-WV-BEPR-09.1 App. 7/09