Hospital Discharge Appeal Rights

1
Hospital Discharge Appeal Rights

• Cathy Bowles, RN
• Director, Review Services
• WVMI

2
Begins July 2, 2007

• Admissions and discharges starting July 2, 2007

3
Beneficiaries Affected

• FFS Medicare beneficiaries
• Include Medicare Advantage enrollees
• Dual eligible (Medicare Medicaid)
• Eligible for Medicare and another insurance
• Have Medicare as a secondary payor

4
Facilities Affected

• Any hospital that provides inpatient care
• Short Term Acute Care Hospitals
• Long Term Acute Care Hospitals
• Critical Access Hospitals
• Inpatient Psychiatric Care
• Inpatient Rehabilitation Care

5
Transfers

• If transferring to another acute care inpatient
  setting, follow-up copy of IM not required
• Receiving facility (not receiving unit within
  same 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
• Hospital outpatients who are receiving Part B
  services

7
Exclusions to Process (Continued)

• Transfer from one hospital to another hospital
• Admissions for services that Medicare never
  covers or exhaustion of Part A days
• Outpatient departments (ED, observation)

8
Issuance of Important Message (IM)

• OMB Approval 0938-0692
• Must issue IM within two calendar days of
  admission
• Must obtain signature of patient or
  representative
• If beneficiary refuses to sign, date of refusal
  is noted as date of receipt

9
Issuance of Important Message (IM)

• Patient unable to sign and representative
  unavailable
• Copies of form are left at bedside and in chart
• Facility must contact representative by phone,
  explain IM and note understanding on IM under
  additional information space
• 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
Issuance of Important Message (IM) (Cont.)

• Original IM is provided to patient or
  representative
• Copy of IM kept by facility
• PreAdmission notification
• Provided no more than seven calendar days prior
  to actual admission

11
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

12
Timing of Notice Delivery

• Admitted on Monday
• Given IM on Wednesday
• Discharged on Friday (follow up copy of IM not
  required)

13
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 patients condition changes and he or she is
  not discharged, another follow up IM should be
  delivered within two calendar days of new
  discharge date

14
Detailed Notice

• Must be OMB approved notice Approval Number
  0938.1019
• 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

15
Request for Expedited Review

• Request for review made no later than midnight of
  the day of discharge
• QIO available seven days a week from 830 a.m.
  till 500 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
  QIOs notification

16
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 cant be held liable if SNF bed becomes
  unavailable

17
QIO Process

• If FFS Medicare Beneficiary Upon notification
  by QIO, hospital must supply medical record, copy
  of IM and copy of Detailed Notice
• If MA Plan Enrollee MA Plan supplies all
  information to QIO, but MA Plan may request
  hospital to furnish the information to QIO
• QIO is required to contact the MA Plan to request
  the information

18
QIO Process Continued

• WV/DE Week-end reviews are usually performed
  by PA staff
• Information must be supplied no later than noon
  of the day after QIO notification
• If the needed information is not provided
  timely, the hospital or MA Plan may be held
  financially liable for extended services

19
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
• Copy for patient copy for record
• If invalid
• Hospital may need to re-issue IM
• QIO proceeds with review process
• QIO educates hospital retrospectively

20
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
• QIO must provide opportunity for hospital and MA
  Plan to explain why discharge is appropriate

21
QIO Process (Cont.)

• QIO must make decision within one calendar day
  after receiving all necessary information
• QIO will notify (telephonically) beneficiary or
  representative, hospital, MA Plan, and physician
  of decision
• Telephone notification will be followed up with a
  letter

22
QIO Process (Cont.)

• 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

23
QIO Process (Cont.)

• If beneficiary or representative remains as
  inpatient and is dissatisfied with QIO decision,
  a reconsideration may be requested

24
QIO Reconsideration Process

• 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
  determination
• QIO has three days to process reconsideration and
  notify all parties

25
QIO Reconsideration Process

• 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

26
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 necessary information to
  make decision
• Patient not protected from liability during
  untimely appeal

27
Untimely Requests for Review

• 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

28
Untimely Requests for Review

• MA Plan Enrollee
• Untimely requests from an MA Plan enrollee,
  enrollee must contact the MA Plan

29
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

30
Preadmission/Admission HINNs

• Revised model language
• Same valid delivery requirements as for IM
• Same reconsideration process

31
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

32
Hospital Requested Review

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

33
Hospital Requested Review

• 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 working days of
  receipt of necessary information

34
Hospital Requested Review

• Hospital provides information to QIO day after
  the request is submitted to QIO
• Patient becomes liable on Noon of day after QIO
  notification
• Follows same reconsideration process

35
QIO Availability for HINNs

• Accepts hospital requests for Preadmission/admiss
  ion HINNs and Hospital-Requested Review for QIO
  concurrence during regular working hours
• Performs these reviews Monday through Friday
• List ONLY Preadmission and Admission Notices on
  monthly HINN log beginning July 2007

36
Contact Information For IM

• West Virginia Medical Institute
• 3001 Chesterfield Place
• Charleston, WV 25304
• Phone number for IM
• 1-800-642-8686 ext. 2266

37
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_at_cms.hhs.gov

38
Process Questions

• Cathy Bowles, RN
• Director, Review Services
• Phone [phone], extension 4256
• E-mail cbowles_at_wvmi.org

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.
Publication number 8SOW-WV-REV07.15. App.
6/27/2007.