notification of hospital discharge appeal rights provider and qio responsibilities

1. Notification of Hospital Discharge Appeal Rights Alice Vallar, RN, MPS IPRO Hello, this is [presenter name] from [QIO name], the Medicare Quality Improvement Organization for [state/jurisdiction]. Today, I�m going to explain the changes to the Medicare hospital discharge appeal process and how these changes affect inpatient hospital providers and the QIO.Hello, this is [presenter name] from [QIO name], the Medicare Quality Improvement Organization for [state/jurisdiction]. Today, I�m going to explain the changes to the Medicare hospital discharge appeal process and how these changes affect inpatient hospital providers and the QIO.

2. 2 Some of these changes may seem to be unnecessarily complicated. As you probably are aware, the changes are the result of a lawsuit, Weichardt vs. Leavitt. The changes to the process require that providers communicate with patients regarding their discharge plans and that all patients whose stay is reimbursed by Medicare be informed of discharge appeal rights. Details of the changes can be found in the Final Rule CMS-4105-F entitled Notification of Hospital Discharge Appeal Rights.Some of these changes may seem to be unnecessarily complicated. As you probably are aware, the changes are the result of a lawsuit, Weichardt vs. Leavitt. The changes to the process require that providers communicate with patients regarding their discharge plans and that all patients whose stay is reimbursed by Medicare be informed of discharge appeal rights. Details of the changes can be found in the Final Rule CMS-4105-F entitled Notification of Hospital Discharge Appeal Rights.

3. 3 Inpatients on July 2 Admissions and discharges starting Monday, July 2 Inpatients on July 2 subject to new notice requirements before discharge The new notice and appeal requirements should be implemented starting on Monday July 2. Patients who are in the facility on July 2 should receive the new IM before being discharged.The new notice and appeal requirements should be implemented starting on Monday July 2. Patients who are in the facility on July 2 should receive the new IM before being discharged.

4. 4 Important Message from Medicare Standardized appeal and liability info All Medicare patients and Medicare Advantage (MA) plan enrollees All inpatient hospitals The new IM replaces the previous IM given to Medicare patients upon admission. The new IM, along with the Detailed Notice, replaces the HINN and NODMAR notices that were previously given to patients who felt they were being discharged too soon. The purpose of the IM is to notify the patient of appeal rights, not to notify them of the discharge date. Providers are not required to send a copy of the IM to the QIO for monitoring, as was required with previous HINNs and NODMARS. The new IM replaces the previous IM given to Medicare patients upon admission. The new IM, along with the Detailed Notice, replaces the HINN and NODMAR notices that were previously given to patients who felt they were being discharged too soon. The purpose of the IM is to notify the patient of appeal rights, not to notify them of the discharge date. Providers are not required to send a copy of the IM to the QIO for monitoring, as was required with previous HINNs and NODMARS.

5. 5 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 The term hospital is defined in the regulation as any facility providing care at the inpatient hospital level, whether that care is 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 care. Discharge is defined as a formal release of a patient from the inpatient level of care. �The term hospital is defined in the regulation as any facility providing care at the inpatient hospital level, whether that care is 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 care. Discharge is defined as a formal release of a patient from the inpatient level of care. �

6. 6 All Medicare Beneficiaries Original Medicare and Medicare Health Plan enrollees Dual Eligible Medicare and Medicaid Medicare Secondary Payer All Medicare beneficiaries are included, no matter where Medicare falls in the sequence of payers. Medicaid patients aren�t included unless they are dual eligible. And beneficiaries with other forms of coverage as the primary payer should receive the Important Message notices.All Medicare beneficiaries are included, no matter where Medicare falls in the sequence of payers. Medicaid patients aren�t included unless they are dual eligible. And beneficiaries with other forms of coverage as the primary payer should receive the Important Message notices.

7. 7 Exclusions Non-covered stay, benefit exhaustion Change from inpatient to outpatient ABN or ABN-type notice appropriate for these situations It�s not appropriate to provide the patient a copy of the IM in situations that can�t be appealed to the QIO, such as a non-covered stay or benefit exhaustion or for Condition Code 44. A notice such as an ABN, informing the patient that the stay is not covered or that the status is changing from inpatient, is appropriate in these situations. A new notice for hospitals to use, the hospital stay ABN or HSABN, is expected to be approved and available on the Medicare Beneficiary Notices Initiative or BNI website, before July 2. The BNI website is an important resource for providers during the transition to the new appeals process. That web address will be given to you at the end of this presentation. It�s not appropriate to provide the patient a copy of the IM in situations that can�t be appealed to the QIO, such as a non-covered stay or benefit exhaustion or for Condition Code 44. A notice such as an ABN, informing the patient that the stay is not covered or that the status is changing from inpatient, is appropriate in these situations. A new notice for hospitals to use, the hospital stay ABN or HSABN, is expected to be approved and available on the Medicare Beneficiary Notices Initiative or BNI website, before July 2. The BNI website is an important resource for providers during the transition to the new appeals process. That web address will be given to you at the end of this presentation.

8. 8 IM Not Used For: Swing beds Outpatient departments (ED, observation) Patients admitted directly to Swing Beds are not given the IM, as they aren�t receiving inpatient services. The Preadmission/Admission HINN or HSABN may be used to inform patients that the stay is non-covered. However, if the Preadmission/Admission HINN is given, the patient has the right to request a QIO review. Patients admitted directly to Swing Beds are not given the IM, as they aren�t receiving inpatient services. The Preadmission/Admission HINN or HSABN may be used to inform patients that the stay is non-covered. However, if the Preadmission/Admission HINN is given, the patient has the right to request a QIO review.

9. 9 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 The IM shouldn�t be given in the rush of the emergency or outpatient departments. If the patient is admitted as an inpatient from these departments, the IM should be given after admission, so that patients fully understand appeal rights. If given during a pre-registration visit, should not be more than 7 calendar days until admissionThe IM shouldn�t be given in the rush of the emergency or outpatient departments. If the patient is admitted as an inpatient from these departments, the IM should be given after admission, so that patients fully understand appeal rights. If given during a pre-registration visit, should not be more than 7 calendar days until admission

10. 10 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 Regarding the discharge date, during the period of public examination of the notices, there were many comments indicating that it was difficult to determine when the exact date of discharge would be, so the date was not included in the IM. The patient will receive a detailed notice if they ask for appeal, or a liability notice if they do not. These notices will contain an effective date. Most patients will not need 4 hours to consider appeal rights, and a patient may go home anytime they are willing. The effective date is the date of the discharge order. However, they should not be pressured to leave prior to being given at least 4 hours to request an appeal, and routine delivery during the rush to make discharge arrangements should be avoided, it at all possible. Regarding the discharge date, during the period of public examination of the notices, there were many comments indicating that it was difficult to determine when the exact date of discharge would be, so the date was not included in the IM. The patient will receive a detailed notice if they ask for appeal, or a liability notice if they do not. These notices will contain an effective date. Most patients will not need 4 hours to consider appeal rights, and a patient may go home anytime they are willing. The effective date is the date of the discharge order. However, they should not be pressured to leave prior to being given at least 4 hours to request an appeal, and routine delivery during the rush to make discharge arrangements should be avoided, it at all possible.

11. 11 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 For a brief admission, the follow-up copy may not be required. If a patient is admitted on Monday, given the initial IM on Wednesday and discharged on Friday, the follow-up copy would not be required as the initial copy would be within 2 days of discharge.For a brief admission, the follow-up copy may not be required. If a patient is admitted on Monday, given the initial IM on Wednesday and discharged on Friday, the follow-up copy would not be required as the initial copy would be within 2 days of discharge.

12. 12 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 If the follow-up copy is given during a preadmission registration, and more than 2 calendar days have elapsed, a follow-up copy of the IM is required, even if the admission is less than 2 days. So if the initial copy is given on the 7th during a pre-registration visit, then the patient is admitted on the 10th and is discharged on the 11th, a follow copy of the IM must be given prior to discharge. If the discharge is delayed after the follow up copy is given, another copy of the IM should be delivered within 2 days of the planned discharge. If the follow-up copy is given during a preadmission registration, and more than 2 calendar days have elapsed, a follow-up copy of the IM is required, even if the admission is less than 2 days. So if the initial copy is given on the 7th during a pre-registration visit, then the patient is admitted on the 10th and is discharged on the 11th, a follow copy of the IM must be given prior to discharge. If the discharge is delayed after the follow up copy is given, another copy of the IM should be delivered within 2 days of the planned discharge.

13. 13 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 For Medicare purposes, if the unit is billing with the same provider number, it would be considered a transfer within the facility and not a discharge. If the patient is transferred to a unit with a different provider number, the transfer would be considered a discharge. A transfer or discharge from one inpatient hospital setting to another inpatient hospital setting does not require the follow up copy of the notice prior to leaving the original hospital, since this is considered the same level of care, and the appeal rights do not apply. However, if the inpatient transfer involves discharge from one inpatient facility and readmission to another inpatient facility that is billed with a different provider number, the receiving hospital must deliver the Important Message from Medicare again. For Medicare purposes, if the unit is billing with the same provider number, it would be considered a transfer within the facility and not a discharge. If the patient is transferred to a unit with a different provider number, the transfer would be considered a discharge. A transfer or discharge from one inpatient hospital setting to another inpatient hospital setting does not require the follow up copy of the notice prior to leaving the original hospital, since this is considered the same level of care, and the appeal rights do not apply. However, if the inpatient transfer involves discharge from one inpatient facility and readmission to another inpatient facility that is billed with a different provider number, the receiving hospital must deliver the Important Message from Medicare again.

14. 14 Communicate the Plan Inform patients of transfer and discharge plans Involve team if there are questions about transfer Most patients will not question their discharge and are anxious to go home. And a patient being transferred to another acute inpatient setting is usually agreeable to receiving further care. One result of the changes to the process is that after receiving the IM, patients may ask more questions about the discharge or transfer plan. As with the previous HINN process, it is not appropriate to issue a HINN when the patient questions transfer to a long-term, rehab or other acute care facility, as HINN regulations and review address discharge and liability, and not appropriateness of the treatment plan. If the patient does question an inpatient transfer, the provider should utilize a case management approach to explore options with the patient and physician and work out a plan that is agreeable. A patient may always refuse care or contact the QIO if they have a quality of care concern. Most patients will not question their discharge and are anxious to go home. And a patient being transferred to another acute inpatient setting is usually agreeable to receiving further care. One result of the changes to the process is that after receiving the IM, patients may ask more questions about the discharge or transfer plan. As with the previous HINN process, it is not appropriate to issue a HINN when the patient questions transfer to a long-term, rehab or other acute care facility, as HINN regulations and review address discharge and liability, and not appropriateness of the treatment plan. If the patient does question an inpatient transfer, the provider should utilize a case management approach to explore options with the patient and physician and work out a plan that is agreeable. A patient may always refuse care or contact the QIO if they have a quality of care concern.

15. 15 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 Per Medicare, the only modifications that can be made to the Important Message and Detailed Notice are adjustments to the spacing at the top and bottom, and the items in the header can be moved around to accommodate a patient label. Items can't be removed or reformatted in the body of the notice in any way, other than is stated in the instructions. This would prohibit changes like moving the signature line and adding the hospital logo. Per Medicare, the only modifications that can be made to the Important Message and Detailed Notice are adjustments to the spacing at the top and bottom, and the items in the header can be moved around to accommodate a patient label. Items can't be removed or reformatted in the body of the notice in any way, other than is stated in the instructions. This would prohibit changes like moving the signature line and adding the hospital logo.

16. 16 Valid Delivery Requirements Within mandated timeframes Copy for patient; copy for record If refuses, note date of refusal as date of receipt To meet valid delivery requirements, the IM must be delivered within the timeframes previously explained. Medicare has said that valid delivery of the Important Message and ensuring that beneficiaries are informed of appeal rights is more important than who gets the original copy of the notice and how the follow-up delivery is done. So any method of notice delivery that provides a legible copy for the patient or representative and retains a copy for the record is acceptable. If it is more convenient for the provider, the patient can be asked to sign a new blank copy at the time of delivery of the follow-up copy associated with the discharge.To meet valid delivery requirements, the IM must be delivered within the timeframes previously explained. Medicare has said that valid delivery of the Important Message and ensuring that beneficiaries are informed of appeal rights is more important than who gets the original copy of the notice and how the follow-up delivery is done. So any method of notice delivery that provides a legible copy for the patient or representative and retains a copy for the record is acceptable. If it is more convenient for the provider, the patient can be asked to sign a new blank copy at the time of delivery of the follow-up copy associated with the discharge.

17. 17 Delivery to Representatives For incompetent patient, use state guidelines to identify responsible person In-person delivery of IM preferred See the Medicare Claims Processing Manual, Chapter 30 section 200 instructions that are posted to the Medicare Beneficiary Notices Initiative website for further information about valid delivery requirements. The person deemed by the hospital to be a valid representative must be acting in the patient�s best interest, or possess written authorization, or as otherwise acceptable to make health care decisions under state guidelines. See the Medicare Claims Processing Manual, Chapter 30 section 200 instructions that are posted to the Medicare Beneficiary Notices Initiative website for further information about valid delivery requirements. The person deemed by the hospital to be a valid representative must be acting in the patient�s best interest, or possess written authorization, or as otherwise acceptable to make health care decisions under state guidelines.

18. 18 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 If patient has no family or responsible person, provider should contact appropriate agency, but can�t assign liability without valid delivery of the IM to a rep acting for the best interests of the patientIf patient has no family or responsible person, provider should contact appropriate agency, but can�t assign liability without valid delivery of the IM to a rep acting for the best interests of the patient

19. 19 Telephone Delivery to a Representative Voice mail not acceptable Provide complete explanation Mail or fax notice on same day Someone must speak directly to a representative If notified by phone all aspects of the IM should be explained A written notice should be mailed or faxed on the same day that the representative is informed of appeal rights by phone Someone must speak directly to a representative If notified by phone all aspects of the IM should be explained A written notice should be mailed or faxed on the same day that the representative is informed of appeal rights by phone

20. 20 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 If there are problems contacting the representative, keep a record of all attempts If unable to deliver by phone, the IM can be sent for signed delivery to a representative The date of delivery would be the date it was signed for as accepted or the date the provider was informed that delivery of the letter was refused If there are problems contacting the representative, keep a record of all attempts If unable to deliver by phone, the IM can be sent for signed delivery to a representative The date of delivery would be the date it was signed for as accepted or the date the provider was informed that delivery of the letter was refused

21. 21 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 QIOs will accept patient requests for discharge appeals 24 hours a day and perform the appeal reviews 7 days a week. QIOs will have a system in place to use voicemail or an answering machine after regular business hours. This aligns Medicare hospital appeals with non-hospital appeals. Providers should find out from their QIO the telephone number that should be listed on the IM, to ensure valid delivery of the notice and prevent delays in discharge appeals. QIOs will accept patient requests for discharge appeals 24 hours a day and perform the appeal reviews 7 days a week. QIOs will have a system in place to use voicemail or an answering machine after regular business hours. This aligns Medicare hospital appeals with non-hospital appeals. Providers should find out from their QIO the telephone number that should be listed on the IM, to ensure valid delivery of the notice and prevent delays in discharge appeals.

22. 22 Timely Patient Request for Appeal Before midnight on the day of planned discharge No patient liability during timely expedited appeal A Medicare patient or representative may request discharge appeal anytime they are informed of a planned discharge, but usually after being given the follow-up copy of the IM. However, for the patient to be protected from liability the QIO must be contacted before midnight on the day of the planned discharge, meaning on the day that the discharge is orderedA Medicare patient or representative may request discharge appeal anytime they are informed of a planned discharge, but usually after being given the follow-up copy of the IM. However, for the patient to be protected from liability the QIO must be contacted before midnight on the day of the planned discharge, meaning on the day that the discharge is ordered

23. 23 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 When contacted, the QIO notifies the hospital (for original Medicare beneficiary) or MA plan (for a MA plan enrollee) ASAP that an appeal has been requested. If the request for appeal is received after hours the QIO contacts the hospital or MA plan the next morning. A Detailed Notice is then issued to the patient. The MA Plan may delegate issuance of the Detailed Notice to the hospital, but it should be issued by noon of the next dayWhen contacted, the QIO notifies the hospital (for original Medicare beneficiary) or MA plan (for a MA plan enrollee) ASAP that an appeal has been requested. If the request for appeal is received after hours the QIO contacts the hospital or MA plan the next morning. A Detailed Notice is then issued to the patient. The MA Plan may delegate issuance of the Detailed Notice to the hospital, but it should be issued by noon of the next day

24. 24 Detailed Notice Must be OMB approved notice Approval No. 0938-1019 Standardized notice containing specific information Like the Important Message,the Detailed Notice is an OMB standardized notice and may not be modified. Detailed notice must contain specific information about the patient�s medical condition, explained in simple terms that a lay person can understand. During the discharge appeal review, the QIO will determine if the IM and Detailed Notice were validly delivered, Like the Important Message,the Detailed Notice is an OMB standardized notice and may not be modified. Detailed notice must contain specific information about the patient�s medical condition, explained in simple terms that a lay person can understand. During the discharge appeal review, the QIO will determine if the IM and Detailed Notice were validly delivered,

25. 25 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 The QIO and provider or MA plan will coordinate to decide what information is needed to complete a specific discharge appeal If the patient requests a copy of the documentation to be sent to the QIO, the provider or MA plan may charge a reasonable fee to cover the costs, but must provide the information by no later than the first day after the material is requested The QIO and provider or MA plan will coordinate to decide what information is needed to complete a specific discharge appeal If the patient requests a copy of the documentation to be sent to the QIO, the provider or MA plan may charge a reasonable fee to cover the costs, but must provide the information by no later than the first day after the material is requested

26. 26 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 As part of the discharge appeal, the QIO will require documentation and verification from the patient or representative that the notices were validly delivered If a SNF bed is needed, the copy of the IM that is delivered within 2 days of d/c shouldn�t be given until a SNF bed is availableAs part of the discharge appeal, the QIO will require documentation and verification from the patient or representative that the notices were validly delivered If a SNF bed is needed, the copy of the IM that is delivered within 2 days of d/c shouldn�t be given until a SNF bed is available

27. 27 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 QIO responsibilities include contacting the hospital, patient, attending physician and MA plan for information and comments related to the patient�s condition and the planned discharge After the expedited determination decision is made, the QIO contacts the parties by phone, within one day. A written notice is then sent to the hospital, patient, attending physician and MA plan QIO responsibilities include contacting the hospital, patient, attending physician and MA plan for information and comments related to the patient�s condition and the planned discharge After the expedited determination decision is made, the QIO contacts the parties by phone, within one day. A written notice is then sent to the hospital, patient, attending physician and MA plan

28. 28 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 The patient is protected from liability during the timely expedited discharge appeal process. After being notified by the QIO, if the patient remains in the hospital, they would become liable beginning at noon of the next day.The patient is protected from liability during the timely expedited discharge appeal process. After being notified by the QIO, if the patient remains in the hospital, they would become liable beginning at noon of the next day.

29. 29 Untimely Requests Original Medicare beneficiary contacts QIO for untimely appeal MA plan enrollee contacts MA plan with untimely request for discharge appeal If the patient remains in the hospital and doesn�t request appeal in a timely manner, meaning by midnight on the day that the discharge was ordered, they may still request expedited appeal. Patients with Original Medicare will contact the QIO Patients with MA plan coverage will contact the MA planIf the patient remains in the hospital and doesn�t request appeal in a timely manner, meaning by midnight on the day that the discharge was ordered, they may still request expedited appeal. Patients with Original Medicare will contact the QIO Patients with MA plan coverage will contact the MA plan

30. 30 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 The provider and QIO will follow the same process as for a timely request for appealThe provider and QIO will follow the same process as for a timely request for appeal

31. 31 Untimely Requests QIO makes determination and notifies hospital, patient and attending physician within 2 calendar days Patient not protected from liability during untimely appeal The QIO is required to make the determination and notify the parties within 2 calendar daysThe QIO is required to make the determination and notify the parties within 2 calendar days

32. 32 Untimely Requests If patient leaves facility, can request appeal within 30 calendar days Can request appeal at any time for good cause After leaving the facility, the patient has 30 days to request a discharge appeal If the patient has good cause, the QIO can accept a request for a discharge appeal after 30 days After leaving the facility, the patient has 30 days to request a discharge appeal If the patient has good cause, the QIO can accept a request for a discharge appeal after 30 days

33. 33 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 If the patient has left the facility when the request is made, the facility has 30 days to provide the Detailed Notice to the patient and to forward the information to the QIO If the QIO doesn�t receive the information needed to process the appeal, the admission is subject to technical denial The QIO must make a determination and inform the involved parties within 30 days of receiving the informationIf the patient has left the facility when the request is made, the facility has 30 days to provide the Detailed Notice to the patient and to forward the information to the QIO If the QIO doesn�t receive the information needed to process the appeal, the admission is subject to technical denial The QIO must make a determination and inform the involved parties within 30 days of receiving the information

34. 34 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 If the Original Medicare patient remains in the hospital after discharge is ordered, and doesn�t request an appeal, the hospital should issue a limitation of liability notice or ABN. There will be a new Hospital Stay ABN released soon that can be used for this purpose. The MA Plan is responsible in this situation for the denial notice that is given to the plan enrollee, and for guiding the enrollee through the plan�s expedited appeals process. If the Original Medicare patient remains in the hospital after discharge is ordered, and doesn�t request an appeal, the hospital should issue a limitation of liability notice or ABN. There will be a new Hospital Stay ABN released soon that can be used for this purpose. The MA Plan is responsible in this situation for the denial notice that is given to the plan enrollee, and for guiding the enrollee through the plan�s expedited appeals process.

35. 35 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 If the Medicare beneficiary or plan enrollee requests reconsideration of the QIO decision after a timely expedited discharge appeal, the provider may not bill the patient until the recon determination is complete The patient is not protected from liability during the reconsideration processIf the Medicare beneficiary or plan enrollee requests reconsideration of the QIO decision after a timely expedited discharge appeal, the provider may not bill the patient until the recon determination is complete The patient is not protected from liability during the reconsideration process

36. 36 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 The changes to the regulations in CMS-4105-F require QIOs to accept requests for appeals 24 hours a day and perform reviews 7 days a week, when the request is from hospital inpatients who are being discharged. However, the changes do not affect requirements for QIO availability to perform Preadmission/Admission HINNs and Hospital Requested ReviewThe changes to the regulations in CMS-4105-F require QIOs to accept requests for appeals 24 hours a day and perform reviews 7 days a week, when the request is from hospital inpatients who are being discharged. However, the changes do not affect requirements for QIO availability to perform Preadmission/Admission HINNs and Hospital Requested Review

37. 37 Preadmission/Admission HINNs Timeframes and liability protections unchanged IM not appropriate unless later admitted to inpatient status The timeframes related to when a hospital can issue a Preadmission/ Admission HINN, when the patient can request an appeal and regarding the liability for the stay are unchanged. It is not appropriate to issue the Important Message from Medicare to a patient if it is planned to issue a Preadmission/ Admission HINN, unless the patient is later admitted to inpatient statusThe timeframes related to when a hospital can issue a Preadmission/ Admission HINN, when the patient can request an appeal and regarding the liability for the stay are unchanged. It is not appropriate to issue the Important Message from Medicare to a patient if it is planned to issue a Preadmission/ Admission HINN, unless the patient is later admitted to inpatient status

38. 38 Preadmission/Admission HINNs Revised model language Same valid delivery requirements as for IM Same reconsideration process There is a new recommended notice to be used when the patient is admitted for services that are not reasonable and necessary. This notice can be found on the Beneficiary Notices Initiative website. Delivery of the notice is affected by the new notice requirements, meaning the Preadmission/Admission NONC must be validly delivered to a patient who can understand or to a representative acting in the patient�s behalf before liability can be assigned. The patient will be informed of the review determination and reconsideration process by the QIO.There is a new recommended notice to be used when the patient is admitted for services that are not reasonable and necessary. This notice can be found on the Beneficiary Notices Initiative website. Delivery of the notice is affected by the new notice requirements, meaning the Preadmission/Admission NONC must be validly delivered to a patient who can understand or to a representative acting in the patient�s behalf before liability can be assigned. The patient will be informed of the review determination and reconsideration process by the QIO.

39. 39 Hospital-Requested Review QIO concurrence for discharge Revised model language Valid delivery required There is also a new HRR notice to replace HINN 10. This notice can be found on the BNI website. Although use of the new notices for Preadmission/Admission HINNs & HRR aren�t mandated, it is recommended that the suggested language and format be followed so that there won�t be questions about valid delivery and understanding of the notices. There is also a new HRR notice to replace HINN 10. This notice can be found on the BNI website. Although use of the new notices for Preadmission/Admission HINNs & HRR aren�t mandated, it is recommended that the suggested language and format be followed so that there won�t be questions about valid delivery and understanding of the notices.

40. 40 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 After July 2, the policy at CMS will change, and hospitals can request QIO concurrence regarding discharge of MA plan enrollees. It�s expected that providers and MA plans will discuss this beforehand The hospital is responsible for the burden of proof related to the patient�s readiness for discharge. After July 2, the policy at CMS will change, and hospitals can request QIO concurrence regarding discharge of MA plan enrollees. It�s expected that providers and MA plans will discuss this beforehand The hospital is responsible for the burden of proof related to the patient�s readiness for discharge.

41. 41 Hospital-Requested Review Patient becomes liable on noon of day after QIO notification Hold IM associated with planned discharge Follows same reconsideration process The QIO notifies the involved parties and solicits comments as with the other discharge appeals. The patient, provider, attending physician and MA plan are notified of the determination within 2 days. It is not necessary for the provider to issue another non-coverage notice to the patient after the QIO determination, nor is it necessary to give the patient another copy of the IM prior to discharge The QIO notifies the involved parties and solicits comments as with the other discharge appeals. The patient, provider, attending physician and MA plan are notified of the determination within 2 days. It is not necessary for the provider to issue another non-coverage notice to the patient after the QIO determination, nor is it necessary to give the patient another copy of the IM prior to discharge

42. 42 Important IPRO Telephone Numbers On Page 1, Bullet #3 of the revised IMM� �concerns you have about the quality of care,� please insert the following information: IPRO 1-800-331-7767 TTY: 1-866-446-3507 or 516-326-6182 On Page 2, first sub-bullet of the revised IMM� � Steps to Appeal Your Discharge�, please insert the following information: IPRO 1-800-446-2447 TTY: 1-866-446-3507 or 516-326-6182 (Excerpt from IPRO�s MAM 2007-05)

43. 43 Information IPRO will Request when Contacting the Hospital

44. 44 Medicare Hospital Discharge Appeal Process (Traditional Medicare)

45. 45 Medicare Hospital Discharge Appeal Process (Traditional Medicare)

46. 46 MA Plan Enrollee Hospital Discharge Appeal Process

47. 47 Information for Providers www.cms.hhs.gov/BNI Under �Beneficiary Notices Initiative (BNI),� go to link for �Hospital Discharge Appeal Notices� www.cms.hhs.gov/MLNMattersArticles Downloads/MM5622.pdf http://www.cms.hhs.gov/CMSForms/downloads/cms1696.pdf Authorized representative form, CMS-1696-U4, which can be found at the CMS website. You may submit questions to Weichardt_ODF@cms.hhs.gov www.ipro.org nforImation about the changes to the Hospital Discharge Appeals process can be found on the CMS website at www.cms.hhs.gov/BNI. There you will find approved versions of all the new notices, instructions for the notices and updated versions of the Medicare Claims Processing Manual. Check this site frequently for transmittals related to the appeals process. Further questions can be submitted to Weichardt_ODF@cms.hhs.govnforImation about the changes to the Hospital Discharge Appeals process can be found on the CMS website at www.cms.hhs.gov/BNI. There you will find approved versions of all the new notices, instructions for the notices and updated versions of the Medicare Claims Processing Manual. Check this site frequently for transmittals related to the appeals process. Further questions can be submitted to Weichardt_ODF@cms.hhs.gov

48. Alice Vallar, RN, MPS Senior Director Medicare/Federal Health Care Assessment (516) 209-5423 Frances Gordon, RN, MBA Assistant Director Medicare/Federal Health Care Assessment (516) 209-5423