Expedited determinations snf hospice
Download
1 / 39

Expedited Determinations SNF - PowerPoint PPT Presentation


  • 224 Views
  • Uploaded on

Expedited Determinations SNF/Hospice. Cheryl Cook, RN Case Review Project Director. Objectives. Explain the history of the ED process and how this process affects the provider and the patient Determine when it is appropriate to give the notice

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Expedited Determinations SNF' - Olivia


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Expedited determinations snf hospice l.jpg

Expedited DeterminationsSNF/Hospice

Cheryl Cook, RN

Case Review Project Director


Objectives l.jpg
Objectives

Explain the history of the ED process and how this process affects the provider and the patient

Determine when it is appropriate to give the notice

Explain the reconsideration process and how the process affects the provider and the patient

Explain the barriers to effective delivery of the notice

2


How it all began l.jpg
How It All Began

1993 – Lawsuit – Grijalva v. Shalala

First Medicare Advantage appeal – January 1, 2004

Extended to FFS – July 1, 2005

Under the Balanced Budget Act

3


Why it all began l.jpg
Why It All Began

Beneficiaries wanted due process rights

Protect beneficiary rights

Provide financial protections

4


How eds affect you l.jpg
How EDs Affect You

CMS can audit your facility

Invalid notices can cost money

Invalid notices waste time and can confuse patients

Laws pertaining to EDs are federal regulations

5


How the process works l.jpg
How The Process Works

The Medicare Advantage Plan or Provider issues the Notice

The patient or family member calls if they want an appeal

HSAG requests the record

The physician reviews the records

The patient and facility are notified of the decision

6


When to issue a notice l.jpg
When To Issue A Notice

When it is determined that all skilled services are no longer required – SNF

When it is expected that the patient’s life expectancy will be longer than 6 months – Hospice

GENERIC NOTICE is issued whether the patient agrees or disagrees with the discharge!

7


Timing requirements l.jpg
Timing Requirements

Providers

Notice issued 2 days prior to planned discharge – SNF

Notice issued second to the last visit - Hospice

8


Timing requirements9 l.jpg
Timing Requirements

Patient

Must call if appeal is desired by noon of the day before the effective date

9



Provider responsibility l.jpg
Provider Responsibility

Fax a copy of the Generic Notice, Face Sheet, and Detailed Notice

If the patient is a Medicare Advantage patient, the MA issues the Detailed Notice

11


Where to get the notices l.jpg
Where to get the Notices

www.cms.hhs.gov/BNI - Click on

“FFS ED Notices” or “MA ED Notices”

12











Tips for success l.jpg
Tips for Success

Standard notice for all situations

Copy for the patient, copy for the chart

Educate your staff, especially weekend staff

Develop a process and “stick” to it

Short, concise delivery

22


Delays l.jpg
Delays

Failure to submit the information in the time frame can result in a delay in the review

Any costs associated with the delay are NOT the responsibility of the beneficiary

23


The hsag physician l.jpg
The HSAG Physician

Has the option to contact the patient’s physician prior to making a decision

May agree or disagree that the beneficiary is ready to be discharged from skilled services

24


California data l.jpg
California Data

11/08- 4/09

FFS – SNF/Hospice Reviews

191 Reviews – 71% agree with Provider

MA – SNF/Hospice Reviews

1088 Reviews – 70% agree with MA Plan

25


Notification l.jpg
Notification

HSAG will notify the beneficiary and the SNF, Hospice, or Medicare Advantage Organization by close of business the day after we receive all information necessary to make a decision

26


Reconsiderations l.jpg
Reconsiderations

The beneficiary has a right to ask for a reconsideration of HSAG’s decision

The beneficiary does not have the same financial protections during this process

27


More reconsiderations l.jpg
More Reconsiderations

FFS patients – Maximus (the Qualified Independent Contractor) completes the review

Medicare Advantage patients – HSAG completes the review

Another physician not involved with the original decision reviews the chart

28


The next step l.jpg
The Next Step

If the reconsideration does not go in the beneficiary’s favor, he or she can appeal to the Administrative Law Judge (ALJ) – only for financial issues

29


Beneficiary request for documents l.jpg
Beneficiary Request for Documents

Upon request, the SNF, Hospice, or Medicare Advantage Organization must provide the beneficiary with the documentation sent to HSAG

30


Invalid notices l.jpg
Invalid Notices

Wrong form

Doesn’t meet CMS guidelines

Missing documentation

Wrong time frames

Wrong dates

31


Representatives l.jpg
Representatives

Difficult for providers

Legal types

Deferring to state law

No representative on record and patient unable to sign

Defer to facility’s policy

32


Exceptions l.jpg
Exceptions

Greater than 100 days

Therapy caps (Part B)

Admission to higher level of care

Patient leaves AMA

Signed up for Hospice

33


Weekend staff l.jpg
Weekend Staff

Need to:

Know who HSAG is and its role in processing these appeals

Be familiar with the notices

Be able to locate the notice

Know how to re-issue the notice

Know they can give out PHI to HSAG

34


Delivery issues l.jpg
Delivery Issues

Excuses

Patient won’t sign

Patient is not alert

Representative won’t acknowledge

35


Case studies l.jpg
Case Studies

Bob Beneficiary has been in the SNF for three weeks. He has met his physical therapy goals and is being discharged. Bob feels he still has room for more improvement and would like to stay longer. He is mentally alert and acts on his own behalf. Please fill out the Notice of Non-coverage and give it to Bob who will sign for it today.

36


Case studies37 l.jpg
Case Studies

Blanche Beneficiary is in the SNF and has plateaued. She has dementia and is not able to act on her own behalf. Her daughter Brenda is her representative and feels that she can still benefit from therapy. However, Brenda has not been available to deliver the Notice of Non-coverage to and has not been able to be reached by phone. Please fill out the Notice of Non-coverage and describe the delivery process to Brenda.

37


Ed phone number l.jpg
ED Phone Number

1-800-841-1602

Call with any questions – 8:00 am – 4:30 pm PST

7 days a week, 365 days a year

38


Slide39 l.jpg

Over 1 million drug-related injuries occur every year in health care settings. The Institute of Medicine estimates that at least a quarter of these injuries are preventable. To find out how to prevent medication errors, go tohttp://www.hsag.com/ca_drugsafety

www.hsag.com

This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for California, 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 No. CA-9SOW-6.1-062209-03

39


ad