Medicare Learning Collaborative

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Medicare Learning Collaborative

• Focus on HINNs
• Presented by Alice Vallar, RN, BSN, MPS
• Senior Director, IPRO
• March 22, 2005

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This is a MEDICARE collaborative learning
session.

• Although we have received questions on various
  topics. 
• Todays session is NOT about
• Billing Questions
• Medicare Advantage
• Medicaid FFS
• Medicaid Managed and Commercial Managed Care
• Medicaid HINNs
• Code 44 inpatient to outpatient status
• Notice of Discharge
•  

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• Our topic is New York Focus on MEDICARE HINNs
•  
• The OBJECTIVE of todays session is
•  
• To respond to questions about HINNs that the
  Hospital Community in New York has submitted to
  their Hospital Associations.

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(81.3)
(87.6)
(77.6)
Aug. 1, 2002 July 31, 2003
Aug. 1, 2003 July 31, 2004
Aug. 1, 2004 March 4, 2005
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Websites

• http//www.cms.hhs.gov/manuals/10_hospital/ho290.a
  sp_1_5
•  
• Medicare Hospital Manual
• Section 290.2 AND 290.3 Availability and
  Appropriateness of Other Facilities and Services

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Websites

• http//www.cms.hhs.gov/manuals/10_
  hospital/ho400.asp
•  
• Medicare Hospital Manual
• Section 414.3 QIO monitoring of HINNs
• Section 414.4 Hospital issuance of HINNs
• Section 414.5 Acknowledgment of Receipt
• Section 414.6 Inappropriate HINN
• Section 414.7 Beneficiary liability
• Section 414.11 Model letters

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Websites

•  http//www.cms.hhs.gov/medicare/bni/
• Medicare Beneficiary Notice Initiative  
• This CMS website indicates that the purpose of
  the CMS Beneficiary Notices Initiative BNI is
  to wed consumer rights and protections with
  effective beneficiary communication so that
  beneficiaries are given the opportunity to timely
  exercise their rights and protections in a
  well-informed manner. 
• Model notices with instructions can be found
  here.

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Websites

• http//www.cms.hhs.gov/manuals/12_snf/sn201.asp_1
  _16
•  
• Medicare Skilled Nursing Facility Manual
• Section 214 Covered Services

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Question 1

• Please provide an overview of the different types
  of HINNs and when they are issued (i.e.,
  preadmission/admission and continued stay).
  Please also include a discussion of physician
  concurrence and describe the process for issuing
  notices when a physician is not in agreement. Is
  physician agreement required when issuing an
  admission HINN?

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Answer 1

• According to the Medicare Hospital Manual
• A.  Preadmission/Admission Notices of
  Noncoverage issue a notice of noncoverage when
  you determine that the admission is not medically
  necessary, is inappropriate, or is custodial in
  nature. You need not obtain the attending
  physicians concurrence or the QIOs prior to
  issuing the preadmission or admission notice of
  noncoverage.

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Answer 1 (cont)

• B.    Continued Stay Notices of Noncoverage. You
  may issue a continued stay notice of noncoverage
  when you determine that a beneficiary no longer
  requires continued inpatient care and either the
  attending physician or the QIO concurs. Before
  you can issue a continued stay notice of
  noncoverage, you must consider the admission to
  be covered.

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Answer 1 (cont)

• 1.    Attending Physician Concurs. If the
  attending physician concurs in writing (e.g.,
  written discharge order) with your determination
  that the beneficiary no longer requires inpatient
  care, you may issue a notice of noncoverage to
  the beneficiary.

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Answer 1 (cont)

• 2.    Attending Physician Does Not Concur. Issue
  a notice to the beneficiary (or his/her
  representative) (Exhibit 10) when the
  beneficiarys physician disagrees with your
  proposed notice of noncoverage and the QIO is
  requested to review the case. You may use your
  own letterhead, but may not alter or change the
  language. Give the notice to the beneficiary (or
  his/her representative) concurrently when you
  request the QIOs review.

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Question 2

• Can the patient designate a representative to
  accept the HINN even if they are alert and
  oriented and have decisional capacity?
•  
• YES, The beneficiary can complete the
  authorized representative form, CMS-1696-U4,
  which can be found at the CMS website.
• http//www.cms.hhs.gov/forms/
•  

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Question 3

• If the patient has designated a family member as
  an authorized representative, can another family
  member or the patient appeal the HINN?
•  
• YES. The beneficiary can appeal. If a family
  member calls, IPRO will accept the call
  requesting the HINN review. However,
  information about IPROs review determination
  will be sent only to the beneficiary or to the
  authorized representative.
•  

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Question 4

• Please identify the parties that should receive
  the HINN. 
• The model letters in the Medicare Hospital Manual
  indicate that the notice , which is addressed to
  the beneficiary , is delivered to the beneficiary
  /Representative with a cc to the QIO and the
  Attending Physician. 
• The HINN Fact Sheet General Guidelines which
  was prepared and distributed by GNYHA in 2001
  also indicates that copies are sent to the
  medical record, UR department files and Hospital
  Billing office.
•  

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Question 5

• Please describe the additional levels of appeal
  once the QIO has issued its determination and in
  your explanation please include who is eligible
  to exercise these further levels of appeal.

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Answer 5

• According to the Medicare QIO Manual A
  beneficiary dissatisfied with the QIOs denial
  determination may obtain a reconsideration of the
  following issues
• Appropriateness of the setting in which the
  services were, or are proposed, to be furnished.
  (See 1154(a)(1)(c) of the Act.)
• Reasonableness, medical necessity and
  appropriateness of the services furnished or
  proposed to be furnished (e.g., whether treatment
  was appropriate for the condition). (See
  1862(a)(1) or (9) and 1154(a)(1)(A) of the
  Act.)
• The Hospital/physician can also request a
  reconsideration.

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Answer 5 (cont)

• Beneficiaries may appeal any medical necessity or
  appropriateness of setting determination
  reconsideration determination made by QIO to an
  administrative law judge (ALJ) where there is at
  least 100 or more at issue. (See 42 CFR 473.40.)
  The Office of Hearings and Appeals (OHA) of the
  Social Security Administration (SSA) conducts
  these hearings.
• The Hospital/physician can request an ALJ hearing
  regarding liability for payment where there is at
  least 100 at issue.

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Question 6

• Please outline the timeframes associated with the
  HINN process.  
• Source Medicare QIO Manual
• Hospital preadmission notice -- If the
  beneficiary or his/her representative disagrees
  with the hospital preadmission notice, he/she may
  request a QIO immediate review, by telephone or
  in writing, within 3 calendar days of receipt of
  the HINN. 

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Answer 6 (cont)

• If admitted, the beneficiary or his/her
  representative may request QIO review at any
  point during the stay.  
• In either situation the QIO reviews the case
  within 2 working days following the beneficiary's
  or his/her representative's request and receipt
  of requested medical record information, and
  issues either a denial notice or a notice
  explaining that the care would be, or is,
  covered.

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Answer 6 (cont)

• IF the QIO agrees with the HINN, the beneficiary
  liability for payment is based on the time and
  date of the beneficiarys receipt of the
  Hospitals notice.  
• Review After Discharge or When Beneficiary Was
  Not Admitted to Hospital -- The beneficiary or
  his/her representative may request review within
  30 calendar days after receipt of the notice.
  Complete this review within the timeframe
  specified for any retrospective review

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Answer 6 (cont)

• Continued-stay HINN -- The beneficiary or his/her
  representative may request QIO review when the
  hospital issues a continued-stay notice of
  non-coverage with the concurrence of the
  attending physician.
• Beneficiary Request for QIO Immediate Review of a
  HINN -- If the beneficiary or his/her
  representative disagrees with the HINN and
  remains in the hospital, he/she may request (not
  later than noon of the first working day after
  the day the notice was received) an immediate
  review by the QIO. This request for review may be
  made by telephone or in writing.

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Answer 6 (cont)

• The hospital must provide the medical records by
  close of business of the first working day after
  the date that the beneficiary receives the
  notice.  
• The QIO completes the requested review and
  notifies the beneficiary or his/her
  representative, the attending physician, and the
  hospital of your determination (whether adverse
  or favorable) within one full working day after
  the date of receiving the request and the
  required medical records.

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Answer 6 (cont)

• If the QIO agrees with the HINN, the beneficiary
  is liable for payment on the day AFTER the QIO
  notifies the beneficiary of its determination.
• Other Review While the Beneficiary Is In the
  Hospital If the beneficiary or his/her
  representative does not request your review by
  noon of the first working day after receipt of
  the HINN and remains in the hospital, he/she may
  still request QIO review at any point during the
  stay. The request may be made by telephone or in
  writing. The QIO reviews the case within 2
  working days following the beneficiary's or
  his/her representative's request.
•  

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Answer 6 (cont)

• IF the QIO agrees with the HINN, the beneficiary
  liability for payment is based on the time and
  date of receipt of the Hospitals notice.  
• Review After Discharge -- If the beneficiary is
  discharged from the hospital, he/she or his/her
  representative may still request review within 30
  calendar days after receipt of the HINN or at any
  time, for good cause. The QIO completes this
  review within 30 calendar days of receipt of the
  medical records, and issues either a denial
  notice or a notice explaining that the care is
  covered.

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Answer 6 (cont)

• IF the QIO agrees with the HINN, the beneficiary
  liability for payment is based on the time and
  date of receipt of the Hospitals notice.

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Answer 6 (cont)

• Continued Stay HINN--Attending Physician Does Not
  Concur
• The hospital is required to give a notice to the
  beneficiary (or his/her representative) when the
  beneficiary's physician disagrees with the
  hospital's proposed notice of noncoverage and
  requests the QIO to review the case. (See
  414.11 of the Hospital Manual, Exhibit 10.) The
  hospital may use its own letterhead, but may not
  alter or change the language. The notice must be
  given to the beneficiary (or his/her
  representative) concurrently when the hospital
  requests QIO review. The hospital may request,
  either by phone or in writing, that you review
  the case immediately. The QIO completes review
  within 2 working days of receipt of medical
  records. If the QIO concurs with the hospital's
  decision, the Hospital may issue its HINN .

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Question 7

• Please explain the financial ramifications to the
  consumer when the patient/family fails to appeal
  in a timely manner.
•  
• For a Continued Stay HINN, when the beneficiary/
  Rep does not appeal by noon of the next working
  day after receipt of the HINN misses the noon
  deadline, the beneficiarys liability is based
  on the date of the beneficiarys/Reps receipt of
  the HINN if the QIO agrees with the HINN.
•  

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Question 8

• Similarly, please explain how the date related to
  financial responsibility changes when the
  provider fails to promptly submit the medical
  record.
•  
• The timeframe for QIO review is based on the date
  of receipt of the medical record from the
  hospital. Delaying delivery of the medical
  record could affect the establishment of the
  beneficiary liability for payment date.
•  

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Answer 8 (cont)

• For example, if the medical record for an
  immediate review of a continued stay HINN should
  have been sent by the hospital to be received at
  IPRO by March 22nd, 2005 but was not received
  until March 24th, IPROs review determination
  would be due by March 25th and, if we agree with
  the HINN, liability for payment by the
  beneficiary would be established as March 26th.
•  

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Question 9

• If the patient has designated an authorized
  representative and the authorized representative
  is not available to receive the HINN, please
  describe the other options and associated
  timeframes for delivering the HINN to the
  representative. When does financial liability
  begin?
•   

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Answer 9 (cont)

•  Source Medicare Hospital Manual
• Acknowledgment of Receipt.--Document the date and
  time of the beneficiarys (or his/her
  representatives) receipt of the HINN. Obtain an
  acknowledgment of receipt (including date and
  time) signed by the beneficiary (or his/her
  representative). A copy of this acknowledgment is
  to be kept in the medical records.
• If the beneficiary (or his/her representative)
  refuses to sign the acknowledgment, immediately
  write on the HINN that the patient refused to
  sign and prepare a report for your files (i.e.,
  medical records). The date of refusal is then
  considered the date of receipt.

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Answer 9 (cont)

• You the Hospital are responsible for
  determining whether the beneficiary, upon
  admission, is mentally competent and capable of
  transacting business (as opposed to being
  incapable of handling his/her own affairs, unable
  to sign and negotiate checks). Develop procedures
  to use when the beneficiary is incapable or
  incompetent and you the Hospital cannot obtain
  the signature of his/her representative through
  direct personal contact. When you the Hospital
  mail the notice to the beneficiarys
  representative, phone the beneficiarys
  representative simultaneously. The date of the
  phone conversation is the date of receipt of the
  notice.

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Answer 9 (cont)

• When direct phone contact cannot be made, send
  the notice to the representative by certified
  mail, return receipt requested. The date that
  someone at the representatives address signs (or
  refuses to sign) the receipt is the date of
  receipt. In considering the different procedures
  that each postal station may have in handling
  "return receipt requested mail," the following
  procedure used by hospitals is considered
  acceptable. For a HINN sent by certified mail,
  return receipt requested, which is returned to
  the hospital with no indication of a refusal
  date, the hospital determines the beneficiarys
  liability starting on the second working day
  after the hospitals mailing date (postmarked by
  the postal station). For example. Postmark date
  March 22nd Tuesday . Beneficiary liability
  date March 24th Thursday.

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Question 10

• Can the hospital issue the HINN by facsimile
  or via Fedex or other express messenger service
  and if so, how would this affect the date that
  the providers enters on the HINN whereby the
  beneficiary would be financially responsible?

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Answer 10 (cont)

• The Medicare Hospital Manual also indicates
  Employ other procedures that have been reviewed
  and approved by the QIO and when needed for
  review, provide the QIO with proof of proper
  notification. This directive applies when the
  Hospital employs other methods of delivery as
  described in the above question. Simply sending
  the HINN notice by fax or leaving a message on
  voicemail is not acceptable. There must be
  documented evidence that the Representative
  received the HINN notice when sent via Fedex or
  messenger. Evidence could be the dated signature
  of the Rep on the Fedex receipt, or dated
  signature of the Fedex/messenger with the
  statement that the addressee refused to
  sign/accept the package.

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Answer 10 (cont)

• Liability date for payment by the beneficiary is
  based on the notification date. For example, if a
  continued stay notice was faxed by Hospital to
  the Rep and the Rep signed it on March 22nd, then
  beneficiary liability for payment would begin
  March 25th. If the Rep contacted IPRO for a
  review of the HINN, the hospital would be
  required to provide evidence that the Rep signed
  the notice on March 22nd for example, a copy of
  the signed/dated notice that was faxed back to
  the Hospital in order to establish that the
  notice was delivered appropriately.

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Question 11

• Do weekend days affect the timing?
•  
• YES. Beneficiaries can request immediate review
  by the next WORKING day after receipt of HINN.
  For example, if a beneficiary receives the HINN
  on Friday, an immediate review can be requested
  by noon on Monday. If Monday is a holiday, then
  by noon on Tuesday.
•  

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Answer 11(cont)

• QIO review timeframes are based on WORKING days.
  For example, if a medical record is received on
  Friday and review timeframe is 2 working days,
  determination is due by close of business on
  Tuesday.

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Question 12

• If a HINN is issued to a patient on Thursday and
  the patient appeals the decision prior to noon of
  the next business day, that is Friday, when does
  financial responsibility begin? (this assumes the
  hospital submits all necessary information to
  IPRO by Friday for its review) 
• IPROs review should be completed and the
  beneficiary is notified on Monday. If IPRO
  agrees with the HINN, beneficiary is responsible
  for payment on Tuesday.

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Question 13

• Same question with the caveat that if Monday is a
  holiday, what date should the hospital enter on
  the HINN informing the patient that if he/she
  remains in the hospital, he/she will be
  financially responsible? Is it Monday, Tuesday or
  other?  
• If the hospital issued the HINN to the
  Beneficiary on Friday, the hospital indicates
  that the liability for payment would begin on
  Monday (Holiday). If the beneficiary did not
  call IPRO on Tuesday for an immediate review and
  remained in the hospital, the liability for
  payment would begin on Monday.

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Question 14

• Is IPRO available to conduct HINN appeals on
  weekends and holidays?
•  
• As per current Medicare regulations, IPRO
  conducts HINN review during regular business
  hours on working days.

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Question 15

• To ensure an appeal is attended to timely when
  the patient files a HINN appeal, what mailing
  address should hospitals use when sending the
  medical record and associated correspondence to
  IPRO? Should it be sent to the attention of
  someone in particular?

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Answer 15

• All envelopes including the outside envelope
  should be addressed as follows for all medical
  records and requested documentation that is sent
  related to immediate HINN reviews 
• IPRO
• 1979 Marcus Avenue
• Lake Success, NY 11042
• ATTENTION NONCOVERAGE DEPARTMENT

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Question 16

• A hospital is seeking placement in a nursing
  facility for a Medicare Beneficiary who is
  receiving skilled services. In this case, the
  nursing facility admission would be Medicare
  covered. As a requirement for admission/ offering
  a bed, can a nursing facility require "financial
  information related to a secondary payer" from
  the Medicare beneficiary/ Representative?

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Answer 16

• The following answer has been provided to the QIO
  community. There are a number of regulations
  that address what a nursing home may require from
  an individual seeking placement. There does not
  appear to be any prohibition on requiring
  financial information related to a secondary
  payer. Please see the text of the following
  regulation
• 42 C.F.R. 489.22, which addresses special
  provisions applicable to prepayment requirements.
• 42 C.F.R. 483.12 Admission, transfer and
  discharge rights. ?483.12 (d)(3) prohibits a
  nursing facility from charging, soliciting,
  accepting, or receiving any gift, money,
  donation, or other consideration as a pre-
  condition of admission or continued stay in the
  facility. and 42 C.F.R. 483.10(c) gives the
  resident the right to manage his or her financial
  affairs.

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Question 17

• What, if any, is the appropriate beneficiary
  notice to give if a patient is ready to be
  discharged from observation services, but the
  patient objects.  No admission is involved.

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Answer 17 (cont)

• The following answer to the above question has
  been provided to the QIO community.
• The appropriate ABN to be used in an observation
  situation is the CMS-R-131-G, Advance Beneficiary
  Notice. The instruction for the CMS-R-131 can be
  found in section 40 and 50 of chapter 30 of
  publication 100-4 of the 'Internet Only Manual
  Medicare Claims Processing Manual.

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Answer 17 (cont)

• An excerpt from the above referenced chapter is
  printed below for informational purposes
• 50.1.3 - Where to Obtain the ABN Forms
• (Rev. 1, 10-01-03)
• The online replicable copies of Form CMS-R-131
  forms in PDF format are available online
• English Advance Beneficiary Notice ABN
  (CMS-R-131-G) for general use.
• http//cms.hhs.gov/medicare/bni/CMSR131G_
  June2002.pdf
•  

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Answer 17 (cont)

• Spanish ABN (CMS-R-131-G) for general use.  
• http//cms.hhs.gov/medicare/bni/CMSR131G_
  Spanish_June2002.pdf
• English ABN (CMS-R-131-L) for laboratory tests.
   
• http//cms.hhs.gov/medicare/bni/CMSR131LJune2002.p
  df
• Spanish ABN (CMS-R-131-L) for laboratory tests.
  
• http//cms.hhs.gov/medicare/bni/CMSR131L_
  Spanish_June2002.pdf

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Answer 17 (cont)

• See also the online ABN resources at the CMS
  Beneficiary Notices Initiative Web page at
  http//www.cms.hhs.gov/medicare/bni/ and at CMS
  Medlearn ABN Quick Reference Guide Web page at
  http//www.cms.hhs.gov/medlearn/refabn.asp

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• While we have provided some regulatory
  information, given the of IPRO agreement with
  hospitals HINNs, the following questions are
  also referred to the hospital community for best
  practices discussion.

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Question

• What needs to be documented in the chart when the
  decision is made to issue a HINN?
• According to the Medicare Hospital Manual
  Continued Stay Notices of Noncoverage.--You may
  issue a continued stay notice of noncoverage when
  you determine that a beneficiary no longer
  requires continued inpatient care and the
  attending physician concurs in writing (e.g.,
  written discharge order) with your determination
  that the beneficiary no longer requires inpatient
  care, you may issue a notice of noncoverage to
  the beneficiary.

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Question

• Can a HINN be issued in the following
  circumstance In developing a patients discharge
  plan, a hospital discharge planner assesses that
  the patient is to return to the home setting but
  will require private hire services. However, the
  patient refuses to cooperate with the hospital
  staff to make the arrangements so that a safe
  discharge plan can be put in place.
• There should be documented evidence to
  demonstrate discharge planning efforts and
  involvement of the patient and the patients
  response. When the attending physician documents
  that the patient does not require the acute
  inpatient hospital level of care, in order for
  Medicare to continue coverage, the patient must
  be receiving skilled services and awaiting
  placement in an SNF. If these circumstances are
  not present, Medicare will not cover the
  continued stay in the hospital.
•  

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Question

• If a HINN has been issued but the patient returns
  to an acute level of care, please describe the
  process for reinstating Medicare coverage. Is
  there a special letter that should be issued?
• The Medicare Manuals do not contain a required
  letter template for this issue.

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Question

• Based on your experience, please highlight the
  circumstances where you observe that hospitals
  issue HINNs inappropriately.
• No evidence of acknowledgement of receipt of
  notice.
• Patient is receiving skilled services and waiting
  for SNF placement.
• Patient is receiving acute care services
• Patient signed the HINN but the medical record
  documents that the patient is confused.
•  

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• Members of the New York Hospital community can
  share their best practices online using JENY
  (http//jeny.ipro.org under Payment Error and
  Case Review Initiatives.

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• If there are additional questions about HINNs,
  please submit them to your Health
  Care/Professional Associations so that the need
  for future learning sessions can be determined.

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Upcoming Collaboratives

• Coding Topic
• April 14, 2005 11am 1230pm
• Utilization/Admission Review Topic
• May 11, 2005 8am 930am
• Coding Topic
• June 23, 2005 11am 1230pm

3/22/05