notification of hospital discharge appeal rights provider and qio responsibilities sally johnson...
TRANSCRIPT
Notification of Hospital Discharge Appeal Rights
Provider and QIO Responsibilities
Sally Johnson
Arkansas Foundation for Medical Care
This material is distributed by Arkansas Foundation for Medical Care, the Medicare Quality Improvement Organization for Arkansas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.
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What We Will Cover
Changes to the Important Message from Medicare (IM)
Changes in provider and Quality Improvement Organization (QIO) responsibilities and interactions
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Inpatients on July 2
Admissions and discharges starting Monday, July 2
Inpatients on July 2 subject to new notice requirements before discharge
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Important Message from Medicare
Standardized appeal and liability info
All Medicare patients and Medicare Advantage (MA) plan enrollees
All inpatient hospitals
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Definitions
Hospital – includes any inpatient facility, except religious non-medical health care institutions
Discharge – a formal release of a patient from inpatient hospital level of care
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All Medicare Beneficiaries
Original Medicare and Medicare Health Plan enrollees
Dual Eligible Medicare and Medicaid
Medicare Secondary Payer
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Exclusions
Non-covered stay, benefit exhaustion
Change from inpatient to outpatient
• ABN or ABN-type notice appropriate for these situations
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IM Not Used For:
Swing beds
Outpatient departments (ED, observation)
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Timing of Initial Copy
Within 2 days of inpatient admission; or
During pre-registration visit, but not more than 7 calendar days prior to admission
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Timing of Follow-Up Copy
As soon as possible when discharge is planned, but no more than 2 days before
Avoid routine delivery of follow-up IM on day of discharge
At least 4 hours prior to discharge is ideal
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Timing of Follow-Up Copy
Not required if initial copy given within 2 calendar days of discharge
Example:
• Patient admitted on Monday
• Given initial IM on Wednesday
• Discharged on Friday
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Timing of Follow-Up Copy
Initial copy given on 7th (during preadmission visit)
Admitted as inpatient on 10th
Discharged on 11th – IM given
follow-up copy must be given if more than 2 calendar days elapsed since initial copy delivered
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Inpatient to Inpatient Transfers
If transferring to another acute inpatient care setting, follow-up copy of IM not required
Receiving facility (not receiving unit within same facility) delivers initial copy of IM again after transfer to a new facility
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Communicate the Plan
Inform patients of transfer and discharge plans
Involve team if there are questions about transfer
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Valid Delivery Requirements
Standardized Notice (CMS-R-193) found on CMS Beneficiary Notices Initiative (BNI) Website
Notice can’t be modified
Signed and dated, understood by patient or acceptable representative
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Valid Delivery Requirements
Within mandated timeframes
Copy for patient; copy for record
If refuses, note date of refusal as date of receipt
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Delivery to Representatives
For incompetent patient, use state guidelines to identify responsible person
In-person delivery of IM preferred
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Delivery to a Representative
Hospital employee would be considered to have a conflict of interest for liability
Valid delivery to patient or representative required before liability can be assigned
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Telephone Delivery to a Representative
Voice mail not acceptable
Provide complete explanation
Mail or fax notice on same day
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Telephone Delivery to a Representative
Document all contacts in record
If unable to reach representative, send by delivery that requires signature
Date of delivery or date of refusal is date of notification
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QIO Availability for Discharge Appeals
Accepts patient requests for discharge appeals 24 hours/day
Performs appeal reviews 7 days/week
Answering machine or voice mail after hours
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Timely Patient Request for Appeal
Before midnight on the day of planned discharge
No patient liability during timely expedited appeal
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Timely Patient Request
QIO notifies hospital or MA plan ASAP
Hospital or MA plan issues Detailed Notice (CMS-10066) to patient by noon of next day
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Detailed Notice
Must be OMB approved notice Approval No. 0938-1019
Standardized notice containing specific information
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Timely Patient Request
By noon of next calendar day, hospital or MA plan provides “any and all” information QIO needs to make determination
Upon request, hospital or MA plan provides documentation to patient by next calendar day
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Timely Patient Request
QIO determines “Valid Notice” of IM and Detailed Notice
Skilled nursing facility (SNF) placement coordinated with delivery of follow-up copy of IM within 2 days of discharge
Must have available SNF bed to assign liability
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QIO Performs Review
Contacts involved parties for comments
Makes determination within 1 calendar day
Notifies facility, patient or representative, attending physician and MA plan
Phone call followed up in writing
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Liability After Timely Request
If QIO agrees with discharge, patient liability begins at noon of day after QIO notification
If QIO disagrees with discharge, the stay continues to be covered by Medicare or the MA plan
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Untimely Requests
Original Medicare beneficiary contacts QIO for untimely appeal
MA plan enrollee contacts MA plan with untimely request for discharge appeal
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Untimely Appeal
QIO contacts hospital, patient and attending physician
Facility provides Detailed Notice to patient; information to QIO by noon of day after being contacted by the QIO
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Untimely Requests
QIO makes determination and notifies hospital, patient and attending physician within 2 calendar days
Patient not protected from liability during untimely appeal
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Untimely Requests
If patient leaves facility, can request appeal within 30 calendar days
Can request appeal at any time for good cause
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Untimely Requests
Facility provides Detailed Notice to patient and all information needed to the QIO within 30 days of notification of request
QIO notifies parties within 30 days of receiving all information
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No Appeal Requested
For Original Medicare provider issues a liability notice (Section 1879 of the SSA)
MA Plan would deliver notice to enrollee
Liability begins day after discharge ordered
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Reconsiderations
Timely request by inpatient – noon of day following QIO notification
Provider may not bill until reconsideration determination
Untimely recon request follows standard claims appeal process
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QIO Availability for HINNs
Accepts hospital requests for Preadmission/admission HINNs and Hospital-Requested Review for QIO concurrence during regular working hours
Performs these reviews Monday through Friday
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Preadmission/Admission HINNs
Timeframes and liability protections unchanged
IM not appropriate unless later admitted to inpatient status
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Preadmission/Admission HINNs
Revised model language
Same valid delivery requirements as for IM
Same reconsideration process
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Hospital-Requested Review
QIO concurrence for discharge
Revised model language
Valid delivery required
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Hospital-Requested Review
Hospital can request for Medicare beneficiary and for MA plan enrollee
Hospital provides information to QIO
QIO makes determination within 2 working days
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Hospital-Requested Review
Patient becomes liable on noon of day after QIO notification
Hold IM associated with planned discharge
Follows same reconsideration process
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Information for Providers
www.cms.hhs.gov/BNI
• Under “Beneficiary Notices Initiative (BNI),” go to link for “Hospital Discharge Appeal Notices”
• Check site often for updates
• You may submit questions to [email protected]
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Information for Providers
www.afmc.org
Click “Programs” then click Medicare Review Services.
Click “New! Revised Important Message” in box on right
Updates will be posted to this page
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My contact information
Sally Johnson
Beneficiary Relations Director
479-573-7632
Fax: 479-649-0004
Email: [email protected]