Expedited Determinations SNF/Hospice

1. Expedited DeterminationsSNF/Hospice Cheryl Cook, RN Case Review Project Director

2. 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 Explain the reconsideration process and how the process affects the provider and the patient Explain the barriers to effective delivery of the notice 2

3. 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 3

4. Why It All Began Beneficiaries wanted due process rights Protect beneficiary rights Provide financial protections 4

5. 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 5

6. 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 6

7. 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! 7

8. Timing Requirements Providers Notice issued 2 days prior to planned discharge – SNF Notice issued second to the last visit - Hospice 8

9. Timing Requirements Patient Must call if appeal is desired by noon of the day before the effective date 9

10. The Details of the Process 10

11. 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 11

12. Where to get the Notices www.cms.hhs.gov/BNI - Click on “FFS ED Notices” or “MA ED Notices” 12

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22. 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 22

23. Delays 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 23

24. 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 24

25. 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 25

26. Notification 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 26

27. Reconsiderations 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 27

28. 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 28

29. 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 29

30. Beneficiary Request for Documents Upon request, the SNF, Hospice, or Medicare Advantage Organization must provide the beneficiary with the documentation sent to HSAG 30

31. Invalid Notices Wrong form Doesn’t meet CMS guidelines Missing documentation Wrong time frames Wrong dates 31

32. Representatives Difficult for providers Legal types Deferring to state law No representative on record and patient unable to sign Defer to facility’s policy 32

33. Exceptions Greater than 100 days Therapy caps (Part B) Admission to higher level of care Patient leaves AMA Signed up for Hospice 33

34. 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 34

35. Delivery Issues Excuses Patient won’t sign Patient is not alert Representative won’t acknowledge 35

36. 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. 36

37. 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. 37

38. ED Phone Number 1-800-841-1602 Call with any questions – 8:00 am – 4:30 pm PST 7 days a week, 365 days a year 38

39. 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 www.hsag.com 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 39