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Notification of Hospital Discharge Appeal Rights Provider and QIO Responsibilities Sally Johnson Arkansas Foundation for Medical Care This material is.

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Presentation on theme: "Notification of Hospital Discharge Appeal Rights Provider and QIO Responsibilities Sally Johnson Arkansas Foundation for Medical Care This material is."— Presentation transcript:

1 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.

2 2 What We Will Cover  Changes to the Important Message from Medicare (IM)  Changes in provider and Quality Improvement Organization (QIO) responsibilities and interactions

3 3 Inpatients on July 2  Admissions and discharges starting Monday, July 2  Inpatients on July 2 subject to new notice requirements before discharge

4 4 Important Message from Medicare  Standardized appeal and liability info  All Medicare patients and Medicare Advantage (MA) plan enrollees  All inpatient hospitals

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

6 6 All Medicare Beneficiaries  Original Medicare and Medicare Health Plan enrollees  Dual Eligible Medicare and Medicaid  Medicare Secondary Payer

7 7 Exclusions  Non-covered stay, benefit exhaustion  Change from inpatient to outpatient ABN or ABN-type notice appropriate for these situations

8 8 IM Not Used For:  Swing beds  Outpatient departments (ED, observation)

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

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

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

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

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

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

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

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

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

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

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

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

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

22 22 Timely Patient Request for Appeal  Before midnight on the day of planned discharge  No patient liability during timely expedited appeal

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

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

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

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

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

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

29 29 Untimely Requests  Original Medicare beneficiary contacts QIO for untimely appeal  MA plan enrollee contacts MA plan with untimely request for discharge appeal

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

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

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

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

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

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

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

37 37 Preadmission/Admission HINNs  Timeframes and liability protections unchanged  IM not appropriate unless later admitted to inpatient status

38 38 Preadmission/Admission HINNs  Revised model language  Same valid delivery requirements as for IM  Same reconsideration process

39 39 Hospital-Requested Review  QIO concurrence for discharge  Revised model language  Valid delivery required

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

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

42 42 Information for Providers  Under “Beneficiary Notices Initiative (BNI),” go to link for “Hospital Discharge Appeal Notices” Check site often for updates You may submit questions to

43 43 Information for Providers   Click “Programs” then click Medicare Review Services.  Click “New! Revised Important Message” in box on right  Updates will be posted to this page

44 44 My contact information  Sally Johnson  Beneficiary Relations Director  479-573-7632  Fax: 479-649-0004  Email:

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