notification of hospital discharge appeal rights provider and qio responsibilities

Notification of Hospital Discharge Appeal Rights

Provider and QIO Responsibilities

Sally Johnson

Arkansas Foundation for Medical Care

This material is distributed by Arkansas Foundation for Medical Care, the Medicare Quality Improvement Organization for Arkansas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.

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What We Will Cover Changes to the Important Message from

Medicare (IM) Changes in provider and Quality

Improvement Organization (QIO) responsibilities and interactions

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Inpatients on July 2 Admissions and discharges starting

Monday, July 2 Inpatients on July 2 subject to new notice

requirements before discharge

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Important Message from Medicare Standardized appeal and liability info All Medicare patients and Medicare

Advantage (MA) plan enrollees All inpatient hospitals

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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

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All Medicare Beneficiaries Original Medicare and Medicare Health

Plan enrollees Dual Eligible Medicare and Medicaid Medicare Secondary Payer

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Exclusions Non-covered stay, benefit exhaustion Change from inpatient to outpatient

• ABN or ABN-type notice appropriate for these situations

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IM Not Used For: Swing beds Outpatient departments (ED, observation)

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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

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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

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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

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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

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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

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Communicate the Plan Inform patients of transfer and discharge

plans Involve team if there are questions about

transfer

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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

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

receipt

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Delivery to Representatives For incompetent patient, use state

guidelines to identify responsible person In-person delivery of IM preferred

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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

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

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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

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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

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Timely Patient Request for Appeal Before midnight on the day of planned

discharge No patient liability during timely

expedited appeal

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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

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Detailed Notice Must be OMB approved notice Approval

No. 0938-1019 Standardized notice containing specific

information

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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

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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

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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

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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

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Untimely Requests Original Medicare beneficiary contacts

QIO for untimely appeal MA plan enrollee contacts MA plan with

untimely request for discharge appeal

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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

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Untimely Requests QIO makes determination and notifies

hospital, patient and attending physician within 2 calendar days

Patient not protected from liability during untimely appeal

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Untimely Requests If patient leaves facility, can request

appeal within 30 calendar days Can request appeal at any time for good

cause

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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

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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

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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

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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

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Preadmission/Admission HINNs Timeframes and liability protections

unchanged IM not appropriate unless later admitted

to inpatient status

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Preadmission/Admission HINNs Revised model language Same valid delivery requirements as for

IM Same reconsideration process

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Hospital-Requested Review QIO concurrence for discharge Revised model language Valid delivery required

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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

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Hospital-Requested Review Patient becomes liable on noon of day

after QIO notification Hold IM associated with planned

discharge Follows same reconsideration process

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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

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Information for Providers www.afmc.org Click “Programs” then click Medicare

Review Services. Click “New! Revised Important

Message” in box on right Updates will be posted to this page

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My contact information Sally Johnson

Beneficiary Relations Director 479-573-7632

Fax: 479-649-0004 Email: sjohnson@arqio.sdps.org