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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

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Expedited DeterminationsSNF/Hospice

Cheryl Cook, RN

Case Review Project Director

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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


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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


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Why It All Began

Beneficiaries wanted due process rights

Protect beneficiary rights

Provide financial protections


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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


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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


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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!


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Timing Requirements


Notice issued 2 days prior to planned discharge – SNF

Notice issued second to the last visit - Hospice


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Timing Requirements


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


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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


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Where to get the Notices

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

“FFS ED Notices” or “MA ED Notices”


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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


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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


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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


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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


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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


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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


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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


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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


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Beneficiary Request for Documents

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


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Invalid Notices

Wrong form

Doesn’t meet CMS guidelines

Missing documentation

Wrong time frames

Wrong dates


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Difficult for providers

Legal types

Deferring to state law

No representative on record and patient unable to sign

Defer to facility’s policy


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Greater than 100 days

Therapy caps (Part B)

Admission to higher level of care

Patient leaves AMA

Signed up for Hospice


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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


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Delivery Issues


Patient won’t sign

Patient is not alert

Representative won’t acknowledge


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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.


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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.


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ED Phone Number


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

7 days a week, 365 days a year


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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


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