1 / 47

Notification of Hospital Discharge Appeal Rights Provider and QIO Responsibilities

Notification of Hospital Discharge Appeal Rights Provider and QIO Responsibilities. Susan M. Cannon, RN, CPC-A AQAF.

guang
Download Presentation

Notification of Hospital Discharge Appeal Rights Provider and QIO Responsibilities

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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

More Related