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Hospital Discharge Appeal Rights

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Admissions for services that Medicare never covers or exhaustion of Part A days ... Must issue IM within two calendar days of admission ... – PowerPoint PPT presentation

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Title: 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 1-800-642-8686, 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.
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