Hospital Discharge Appeal Rights

1. Hospital Discharge Appeal Rights Cheryl Cook, RN Project Director

2. Overview Sections 1154 and 1866 (a) (1) (M) Beneficiaries have a right to QIO review of discharge decisions Hospitals continue to be responsible for notifying beneficiaries of this right Notification requirements revised by CMS-4105-F 2

3. Medicare Beneficiaries Covered by the Rule Original Medicare and Medicare Health plan enrollees Dual-eligible Medicare and Medicaid Medicare Secondary Payer 3

4. IM: Delivery Requirements for the Initial Copy Within 2 days of inpatient admission During pre-registration visit, but not more than 7 calendar days prior to admission Use standardized notice (CMS-R-193) Ensure beneficiary comprehension Signed and dated by beneficiary 4

5. Hospitals Affected by this Rule Any facility providing care at the inpatient hospital level Short term or long term Acute or non-acute Paid through a prospective payment system or other reimbursement basis Limited to specialty care or providing a broader spectrum of services Includes critical access hospitals 5

6. Hospital Exclusions Swing beds in hospitals when used as skilled nursing beds Outpatient departments (ED, Observation beds) Religious non-medical health care institutions 6

7. IM: Delivery Requirements for the 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 four hours prior to discharge May give new IM and obtain signature again Must document delivery and demonstrate compliance 7

8. Notice Delivery to Representatives For patients unable to speak for themselves, use state guidelines to identify responsible person Delivery should be in person Delivery may be by phone (not by voicemail) with a notice mailed or faxed that same day 8

9. Notice Delivery to Representatives If a representative agrees, notice may be e-mailed following telephone call Electronic transmissions must meet HIPAA requirements If unable to reach by phone, the notice may be sent by certified mail – date of signature or refusal is the date of notification 9

10. Requesting QIO Review Beneficiary must submit a request to the QIO no later than the day of discharge Beneficiary should not be discharged if he/she requests QIO review Request may be in writing or by telephone 10

11. Timely Requests: Liability During the QIO Review Beneficiary is only responsible for coinsurance and deductibles for inpatient hospital services furnished before noon of the day after the QIO notifies the beneficiary of its decision 11

12. Timely Request: Liability after QIO Review QIO agrees with the hospital: Liability for continued services begins at noon of the day after the QIO notifies the beneficiary, or as determined by the QIO QIO agrees with the beneficiary: No beneficiary liability for continued care (other than coinsurance and deductibles) 12

13. Untimely Requests: Liability During QIO Review Beneficiaries who do not request a review and remain in the hospital past the discharge date: May request QIO review at any time May be charged for any services provided after the discharge date Will be refunded any funds collected, if the QIO finds for the patient Beneficiaries who miss the deadline and leave the hospital continue to have the right to request a QIO review within 30 calendar days of the date of discharge 13

14. Hospital Responsibilities During Review Deliver the Detailed Notice of Discharge using the standardized notice. Provide all information the QIO needs by telephone or in writing at the QIO’s discretion. As soon as possible, but not later than noon of the day after the QIO notifies a hospital of the review request, the hospital must: 14

15. Hospital Responsibilities During Review If requested, provide copy of information to beneficiary Burden of proof is on the hospital Failure to give needed information may result in a decision based on evidence at hand or a delay in making the decision 15

16. QIO Responsibilities Notify the hospital of the beneficiary’s request for a review Receive and examine records Determine if notice delivery was valid Solicit the views of the beneficiary Solicit the views of the hospital Issue a decision within the applicable time frame 16

17. QIO Decision-making Time Frames Timely requests – one calendar day after all information is received Untimely request (in hospital) – 2 calendar days after all information is received Untimely request (not in hospital) – 30 calendar days after all information is received 17

18. Special Considerations Inpatient-to-inpatient transfers Preadmission/Admission for services that are not reasonable and necessary Pre/admission/Admission for services Medicare never covers Change of status from inpatient to outpatient End of Part-A days Hospital requested review (42 CFR Part 405.1208) 18

19. Differences for Medicare Health Plans Plan may delegate delivery of the Detailed Notice Review of untimely reviews are done by the plan Hospitals and plans both have responsibilities when providing information to the QIO Hospital-requested QIO reviews should occur only in consultation with the plan 19

20. The NODMAR and HINN NODMAR will no longer be used HINNs for continued stay are no longer used Continue using: Preadmission/Admission HINN New Inpatient Hospital Stay ABN HINN 11 HINN 10 replaced by Notice of Hospital Requested Review (HRR) 20

21. For More Information www.cms.hhs.gov/BNI - Click on “Hospital Discharge Appeal Notices” 21

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30. Case Studies Case Study #1 Bob Beneficiary has been in the hospital for three days. His physician, Dr. Seuss, is discussing discharge and Bob does not feel he is ready to go. Bob is mentally alert and acts on his own behalf. Please fill out the IM and give it to Bob. 30

31. Case Studies Case Study #2 Blanche Beneficiary is currently in the hospital after falling and breaking her hip. Her physician, Dr. Pepper, is considering sending her to rehab. She is not able to act on her own behalf so the discharge planner needs to contact her daughter, Brenda. She has not been able to reach Brenda by phone or give the IM to her in person. Please fill out the IM and describe the process to get it to Brenda. 31

32. 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-6.1-062209-01 32