Hospital Discharge Appeal Rights & QIO Responsibilities

1. Notification of Hospital Discharge Appeal RightsProvider and QIO Responsibilities Susan M. Cannon, RN, CPC-A AQAF This material is distributed by AQAF, the Medicare Quality Improvement Organization for Alabama, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. 8SOW-AL-GEN—08-16

2. What We Will Cover • Important Message from Medicare (IM) • Provider and Quality Improvement Organization (QIO) responsibilities and interactions

3. Important Message from Medicare • Standardized appeal and liability info • All Medicare patients and Medicare Advantage (MA) plan enrollees • All inpatient hospitals

4. 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

5. All Medicare Beneficiaries • Original Medicare and Medicare Advantage Plan enrollees • Dual Eligible Medicare and Medicaid • Medicare Secondary Payer

6. Exclusions • Non-covered stay, benefit exhaustion • Change from inpatient to outpatient (use of Condition Code 44, MedLearn Matters article, SE0622) • Transfer from one inpatient hospital setting to another inpatient hospital setting (includes short-term acute care to long-term acute care)

7. IM Not Used For… • Religious, non-medical health care institutions • Swing beds • Outpatient departments (such as ED, observation-receiving Part B services) • If patient is transferring to unit that bills with the same provider number-considered transfer, not discharge for Medicare purposes-deliver IM within 2 days of d/c

8. Exclusions, continued… • Hospital patients who elect hospice coverage would not receive the follow-up copy of the IM, IF the hospice election occurs prior to discharge from acute care • If Preadmission/Admission HINN or HRR appropriate-covered later in presentation

9. Timing of Initial Copy • Within two days of inpatient admission; or • During pre-registration visit, but not more than seven calendar days prior to admission

10. Timing of Follow-Up Copy • As soon as possible when discharge is planned, but no more than two days before • Avoid routine delivery of follow-up IM on day of discharge or routinely scheduled days during week such as Mon-Wed-Fri • At least four hours prior to discharge

11. Timing of Follow-Up Copy • Not required if initial copy given within two calendar days of discharge • Example: • Patient admitted on Monday • Given initial IM on Wednesday • Discharged on Friday

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 two calendar days elapsed since initial copy delivered

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

14. Communicate the Plan • Inform patients of transfer and discharge plans • Involve team if there are questions about transfer

15. Valid Delivery Requirements • Standardized Notice (CMS-R-193) found on CMS Beneficiary Notices Initiative (BNI) Website • Notice can’t be modified, except as specifically allowed by CMS instructions. • Signed and dated, understood by patient or acceptable representative

16. Valid Delivery Requirements • Within mandated timeframes • Copy for patient; copy for record • If refuses, note date of refusal as date of receipt

17. Delivery to Representatives • For incompetent patient, use state guidelines to identify responsible person • In-person delivery of IM preferred

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

19. Telephone Delivery to a Representative • Voice mail not acceptable • Provide complete explanation • Mail or fax notice on same day

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

21. QIO Availability for Discharge Appeals • Accepts patient requests for discharge appeals 24 hours/day • Performs appeal reviews seven days/week • Answering machine or voice mail after hours

22. Timely Patient Request for Appeal • No later than midnight on the day of planned discharge in writing or by telephone • No patient liability during timely expedited appeal

23. Timely Patient Request • QIO notifies hospital or MA plan ASAP • Hospital or MA plan issues Detailed Notice (CMS-10066) to patient ASAP but not later than noon of next day

24. Detailed Notice • Must be OMB approved notice Approval No. 0938-1019 • Standardized notice containing specific information

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

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 two days of discharge • Must have available SNF bed to assign liability

27. QIO Performs Review • Contacts involved parties for comments • Makes determination within one calendar day • Notifies facility, patient or representative, attending physician and MA plan • Phone call followed up in writing

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

29. Untimely Request • Original Medicare beneficiary contacts QIO for untimely appeal • MA plan enrollee contacts MA plan with untimely request for discharge appeal

30. Untimely Request • 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

31. Untimely Request • QIO makes determination and notifies hospital, patient and attending physician within two calendar days if the patient remains in the hospital. • Patient not protected from liability during untimely appeal

32. Untimely Request • If patient leaves facility, can request appeal within 30 calendar days • Can request appeal at any time for good cause

33. Untimely Request • QIO will contact the facility and request information including medical record, IMs and detailed notice. • The QIO will make its determination and notify all parties of its determination within 30 days after receipt of the request and pertinent information.

34. Liability After Untimely Request • Patient is liable for any charges incurred after the day of discharge or as otherwise stated by the QIO.

35. Patient asks for QIO review • HINN 12 can be issued as soon as the hospital receives the QIO’s determination that the discharge was appropriate; however patient liability cannot begin before noon of the day after the QIO decision is received.

36. Patient does not ask for a QIO review • HINN 12 should be delivered the morning following the discharge date.

37. QIO Availability for HINNs and HRRs • Accepts beneficiary requests for Preadmission/Admission HINNs and Hospital-Requested Review for QIO concurrence during regular working hours • Performs these reviews Monday through Friday

38. Reconsiderations • Original Medicare Beneficiaries • Timely request by inpatient by noon of day following QIO notification of initial decision • QIO notifies all parties of determination within 72 hrs if patient remains hospitalized • Provider may not bill until reconsideration determination made and parties notified.

39. Reconsiderations • MA Plan Enrollees • If still an inpatient in the hospital-QIO does reconsideration review with recommended determination and notification within 72 hrs • If no longer an inpatient-standard or expedited plan appeal process

40. HINN 11 • Used for noncovered items or services provided during an otherwise covered stay.

41. Preadmission/Admission HINNs • Used prior to an entirely noncovered stay • Timeframes, liability and general appeal process are not changed. • IM not appropriate unless later admitted to inpatient status

42. Preadmission/Admission HINNs • This notice can be found on the Beneficiary Notices Initiative website. • Revised model language in Medicare Claims Processing Manual, Chapter 30, 240.6 exhibit 4

43. Hospital-Requested Review • Hospital determines that a Medicare beneficiary or MA plan enrollee no longer needs inpatient care but is unable to obtain the agreement of the physician. • Revised notice-Medicare Claims Processing Manual, Chapter 30, section 225-Exhibit 3 • Valid delivery required

44. Hospital-Requested Review • Hospital can request for Medicare beneficiary and for MA plan enrollee • Hospital provides information to QIO by close of business on first full working day immediately following the day the hospital submits the request for review. • QIO makes determination within two working days

45. Hospital-Requested Review • Patient becomes liable on noon of day after QIO notification if QIO agrees that discharge is appropriate • QIO informs patient/rep of appeal rights

46. Reconsideration • The reconsideration procedures for preadmission/admission HINNs and for hospital- requested expedited reviews are the same as for expedited discharge appeal.

47. 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 Weichardt_ODF@cms.hhs.gov