Title: Hospital Discharge Appeal Rights
1Hospital Discharge Appeal Rights
- Cathy Bowles, RN
- Director, Review Services
- WVMI
2Begins July 2, 2007
- Admissions and discharges starting July 2, 2007
3Beneficiaries Affected
- FFS Medicare beneficiaries
- Include Medicare Advantage enrollees
- Dual eligible (Medicare Medicaid)
- Eligible for Medicare and another insurance
- Have Medicare as a secondary payor
4Facilities 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
5Transfers
- 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
6Exclusions to Process
- Swing beds in hospitals considered lower level
of care - Hospital outpatients who are receiving Part B
services
7Exclusions 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)
8Issuance 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
9Issuance 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
10Issuance 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
11Delivery 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
12Timing of Notice Delivery
- Admitted on Monday
- Given IM on Wednesday
- Discharged on Friday (follow up copy of IM not
required)
13Delivery 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
14Detailed 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
15Request 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
16Skilled 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
17QIO 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
18QIO 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
19QIO 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
20QIO 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
21QIO 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
22QIO 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
23QIO Process (Cont.)
- If beneficiary or representative remains as
inpatient and is dissatisfied with QIO decision,
a reconsideration may be requested
24QIO 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
25QIO 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
26Untimely 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
27Untimely 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
28Untimely Requests for Review
- MA Plan Enrollee
- Untimely requests from an MA Plan enrollee,
enrollee must contact the MA Plan
29Hospital Issued Notices of Noncoverage (HINNs)
- Preadmission and Admission HINN process
unchanged - For MA Plan enrollees preadmission and
admission reviews are responsibility of MA Plan
30Preadmission/Admission HINNs
- Revised model language
- Same valid delivery requirements as for IM
- Same reconsideration process
31QIO 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
33Hospital 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
35QIO 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
36Contact Information For IM
- West Virginia Medical Institute
- 3001 Chesterfield Place
- Charleston, WV 25304
- Phone number for IM
- 1-800-642-8686 ext. 2266
37Important 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 -
-
38Process Questions
- Cathy Bowles, RN
- Director, Review Services
- Phone 1-800-642-8686, extension 4256
- E-mail cbowles_at_wvmi.org
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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.