Expedited Appeals for Medicare Beneficiaries in the Hospital Setting

1. Expedited Appeals for Medicare Beneficiaries in the Hospital Setting June 2007 Cheryl Lehane, RN, CPHQ Manager Medicare Review This material was prepared by Masspro, the Medicare Quality Improvement Organization for Massachusetts, 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 represent CMS policy. 8sow-ma-3a-07-21 ExpAppeal-May

2. Session Overview • Terminology • Background • Preparing and Delivering the Important Message • Preparing and Delivering the Detailed Notice of Disch • Workflow/ Timeline • Masspro Review Process • Resources

3. Objectives • Describe the requirements for issuing the Important Message in the hospital setting as part of patient rights regulations • Explain the components of a “valid” Important Message • Identify key information required by Masspro to conduct a review of an appeal

4. Terminology • Original Medicare • Medicare Health Plans • Medicare Advantage • Private Fee-For-Service (PFFS) • Medicare Cost Plans • Important Message from Medicare (IM) • Appeal • Detailed Notice of Discharge • Hospital: any facility providing care at the inpatient hospital level, whether care is short term, long term, acute or non acute. Includes critical access hospitals.

5. Terminology • Discharge: the formal release of a patient from an inpatient hospital. • Masspro Reviewers • Review case manager (RCM) • Physician Reviewer (PR) • Authorized representative • Masspro’s review determinations • Upheld • Overturned

6. Background/History • Currently this process exists for SNFs, HHAs, and hospice settings • Medicare Advantage (MA) Fast Track established by Grijalva v Shalala (class action lawsuit) • Medicare Benefits Improvement and Protection Act of 2000 (BIPA) Public Law 106-554 described similar process for FFS beneficiaries • Establishes that all Medicare beneficiaries receive written notice when their covered services are about to end, even if they agree that services should end.

7. Regulatory Reference Original Medicare • The instructions that follow stem directly from regulations at 42 CFR 405.1205 and 405.1206 and are effective July 1, 2007. These regulations are also referenced at 42 CFR 489.27 and 412.42 (c)(3). The authority for these instructions stems from Sections 1866(a)(1)(M), 1869(c)(3)(C)(iii)(III), and 1154(e) of the Social Security Act. • These instructions implement 42 CFR 405.1205 and 405.1206 which require hospitals to inform Medicare beneficiaries who are hospital inpatients of their right to a QIO review.

8. Regulatory Reference Managed Medicare • The instructions that follow stem directly from regulations at 42 CFR §422.620 and §422.622 and are effective July 2, 2007. The authority for these instructions stems from sections 1866(a)(1)(M) and section1154(a) of the Social Security Act. • These instructions implement 42 CFR §§ 422.620 and 422.622 that require hospitals and Medicare health plans to inform Medicare enrollees who are hospital inpatients of their right to a QIO review.

9. General Information • Hospitals must notify Medicare beneficiaries who are hospital inpatients of their discharge appeals rights. Hospitals will use a revised version of the Important Message for Medicare (IM) a statutorily-required notice, to explain the beneficiary’s rights as a hospital patient, including discharge appeal rights.

10. General Information • Hospitals must issue the IM within 2 calendar days of admission, must obtain the signature of the beneficiary or representative and provide a copy at that time. Hospitals will also deliver a copy of the signed notice as far in advance of discharge as possible, but not more than 2 calendar days before discharge.

11. General Information • This new process provides information to beneficiaries about the QIO appeal process, right to an expedited determination, and the right to receive detailed information about the discharge decision. • This process replaces the use of continued stay HINNs. • The NODMAR will be discontinued.

12. Definition of a “Valid Important Message” • IM is the standardized notice published by CMS • Meets the IM delivery timeframes • Signed and dated by the beneficiary or a representative

13. Preparing the Important Message • Use of the correct form: • Important Message From Medicare • OMB #0938-0692 (must be displayed) • CMS-R-193 lower portion of page 1 • Available at www.cms.hhs.gov/bni at the link for Hospital Discharge Appeal Notices • This is a standardized form. Do not deviate from the content of the form except where indicated! • Follow the instructions for completing (included in your folder)

14. Preparing the initial Important Message • Insert beneficiary’s name, ID number, attending physician • Beneficiary or representative signs and dates the notice and retains the original. • The hospital retains a copy of the notice. • Insert QIO name (Masspro) and telephone number (800-252-5533) and TTY number (800-429-2370)

15. Delivery of the Important Message • Important Message must be delivered in person (exceptions apply) • Timely delivery is defined as within two days of admission, with a follow-up copy issued not more than 2 calendar days before discharge. • Hospitals may deliver the initial copy of the Important Message if the beneficiary is seen during a preadmission visit, but not more than 7 calendar days in advance of admission.

16. Delivery of the Important Message • A follow-up Important Message must be delivered as far in advance as possible but no more than 2 calendar days before the planned date of discharge. • A copy of the initial Important Message can be the follow up. Hospitals may choose to deliver a new copy of the IM, however the hospital must obtain the beneficiary’s/representative's signature and date on the Important Message at that time. • Delivery of the follow-up copy of the IM as part of the routine process on the day of discharge should be avoided and should not be built into your policy.

17. Delivery of the Important Message • Hospitals must document delivery of the follow-up copy of the signed IM, when applicable, and are responsible for demonstrating compliance with this requirement. If hospitals have processes in place to document delivery of other information related to discharge that includes a beneficiary signature and date, hospitals may include the follow-up copy of the Important Message in those documents. If there are no other existing processes in place, hospitals may use the “Additional Information” section of the IM to document delivery of the follow-up copy, for example, by adding a line for the beneficiary’s or representative’s initials and date.

18. Delivery of the Important Message • If the follow-up copy of the Important Message is delivered on the day of discharge, hospitals must give beneficiaries who need it at least 4 hours to consider their right to request an appeal. • Follow up notification is not required when the initial Important Message is delivered within two calendar days of discharge. • Example: A beneficiary is admitted on Monday, the IM is delivered on Wednesday, and the beneficiary is discharged on Friday. No follow-up Important Message is required.

19. Delivery of the Important Message • If the beneficiary refuses to sign, the hospital may annotate the Important Message to indicate the refusal, and the date of refusal is considered the date of receipt. In a refusal to sign situation, Masspro advises to document that the patient/ representative was made aware of their appeal rights, the time requirements for filing an expedited appeal, and given the contact information for Masspro. This documentation supports that the beneficiary/representative was notified of their rights.

20. Telephonic Delivery of the Important Message • Information, at a minimum, that should be given for telephonic delivery; (as specified in Medicare Claims Processing Manual) • Name and telephone of contact at the hospital; • Planned date of discharge and when liability would begin ; • The beneficiary’s rights as a hospital inpatient, including the right to appeal a discharge decision; • How to get a copy of a detailed notice describing why the hospital and physician believe the beneficiary is ready to be discharged; • When (by what time/date) the appeal must be filed to take advantage of the liability protections;

21. Telephonic Delivery of the Important Message (continued) • The entity required to receive the appeal, including any applicable name, address, telephone number, fax number or other method of communication the entity requires in order to receive the appeal in a timely fashion; • Direction to the 1-800-MEDICARE number for additional assistance in further explaining and filing the appeal.

22. Telephonic Delivery of the Important Message (continued) • The date the hospital conveys this information to the representative, whether in writing or by telephone, is the date of receipt of the Important Message. Confirm the telephone contact by written notice mailed on that same date. Place a dated copy of the Important Message in the beneficiary’s medical file, and document the telephone contact with the beneficiary’s representative (as listed above) on either the form itself, or in a separate entry in the beneficiary’s file or attachment. NOTE: A message left on an answering machine will not support valid delivery!

23. Mail Delivery • When direct phone contact cannot be made, send the Important Message to the representative by certified mail, return receipt requested, or other delivery method that requires signed verification of delivery. The date that someone at the representative’s address signs (or refuses to sign) the receipt is the date received.

24. Mail Delivery • Place a copy of the notice in the beneficiary’s medical file, and document the attempted telephone contact. The documentation should include: • the name of the staff person initiating the contact, • the name of the representative you attempted to contact, • the date and time of the attempted call, • and the telephone number called.

25. Mail Delivery • If both the hospital and the representative agree, hospitals may send the Important Message by fax or email, however, hospitals must meet the HIPAA privacy and security requirements.

26. Appeal Workflow • Beneficiary must call Masspro no later than the day of the planned discharge (midnight) to request an expedited appeal. • Masspro immediately notifies the hospital and the plan (as applicable) when a request is received. • At this point the hospital or the plan prepares the detailed notice of discharge • Masspro will request the medical record, Important Message(s) and the detailed notice of discharge

27. Appeal Workflow • Hospital or Medicare health plan prepares and delivers valid detailed notice of discharge to the beneficiary and the QIO no later than noon of the day after the QIO notification • The hospital/plan submits medical records, the Important Message, and the detailed notice of discharge to the QIO as soon as possible but no later than by noon of the day after the QIO notifies the hospital of the appeal.

28. Preparing the Detailed Notice of Discharge • Use of the correct form: • Detailed Notice of Discharge • OMB # 0938-1019 • CMS 10066 • Available at www.cms.hhs.gov/bni at the link for Hospital Discharge Appeal Notices • This is a standardized notice. Do not deviate from the content of the form except where indicated!

29. Preparing the Detailed Notice of Discharge • Describe in simple terms, the facts surrounding the decision to discharge the patient. Include the following: • Explain why services are no longer necessary • Describe relevant Medicare coverage rules, instructions, or other policies • Use facts specific to the beneficiary and relevant to coverage determination

30. Preparing the Detailed Notice of Discharge • Original Medicare: Hospital must deliver a detailed notice of discharge to the beneficiary no later than noon of the day after the QIO’s notification. • Medicare Health Plan: Detailed notice of discharge is directly or by delegation, delivered to the enrollee no later than noon the day after the QIO’s notification.

31. Appeal Workflow • Masspro follows regulatory requirements and ensures the following: • Valid Important Message • Evidence of valid delivery • Valid detailed notice of discharge • Appeal process does not stop if found to be invalid

32. Appeal Workflow • Masspro makes a review determination within one calendar day after it receives all requested pertinent information. • Decisions rendered within two calendar days when untimely FFS requests are received by the QIO. Liability protection does not apply. • Untimely MA requests must be submitted to the plan. Liability protection does not apply. • RCM Review based on regulations and criteria • PR of all appeals – based on medical judgment and regulatory criteria.

33. Appeal Workflow • Masspro notifies the beneficiary/ authorized representative,the hospital, and the plan if applicable, of the decision by telephone • Masspro follows up with written notification.

34. Payment Liability Issues • Timely appeal – patient protected from liability until noon of the day following the day the QIO decision rendered. • If the QIO does not receive information needed to sustain the hospital decision to discharge, it may base a decision on evidence available or defer a decision until adequate information is received. This delay may result in financial liability to the hospital or plan.

35. Payment Liability Issues • A beneficiary who fails to make a timely request for an expedited determination and remains in the hospital without coverage, still may request an expedited determination at any time during hospitalization, however financial liability protection does not apply • A beneficiary who fails to make a timely request for expedited determination and who is no longer inpatient may request a QIO review within 30 calendar days after the date of discharge (or at any time for good cause).

36. Exceptions to the Requirement • Hospitals are not required to issue an Important Message: • For exhaustion of benefits • For services that Medicare never covers • For observation stays • For preadmission/admission services that are not reasonable and necessary (unless the stay becomes a covered stay)

37. Special Considerations • Inpatient to inpatient transfers • Preadmission/Admission services that are not reasonable and necessary • Preadmission/Admission for services Medicare never covers • Change of status from inpatient to outpatient • Hospital requested review

38. Hospital Issued Notices of Non-coverage Revisions as of July 1, 2007

39. HINN Revisions • Preadmission/Admission HINN slightly revised • Continued stay HINN discontinued • Hospital Requested Review (HRR) new process

40. Hospital Requested Review (HRR) • Applicable to Medicare beneficiaries and Medicare Advantage plan enrollees • Hospital determines that inpatient level of care no longer needed and cannot obtain physician concurrence • Hospitals may request QIO review • Hospitals must notify the MA plan and the enrollee that the review has been requested

41. Contact Information • Cheryl Lehane, RN, CPHQ Manager Medicare Review (781) 419-2753 • Review Case Managers – Expedited Appeals • Pat Harris, LPN (781) 419-2751 • Nancy Steber, LPN (781) 419-2765 • Shivelle Godfrey, LPN (781) 419-2853 • Sherianne Rogers, (781) 419-2879 Helpline Coordinator • Fax number for hospital records: (781) 419-2511

42. Resources • Masspro Website: www.masspro.org • CMS Website: http://www.cms.hhs.gov/BNI • Final Rule: http://www.cms.hhs.gov/BNI/Downloads/CMS-4105-F.pdf

43. Resources • Medicare Claims Processing Manual http://www.cms.hhs.gov/manuals/downloads/clm104c30.pdf • Medicare Managed Care Manual – Pub# 100-16, Chap. 13 http://www.cms.hhs.gov/Manuals/IOM/list.asp?listpage=2 • Form 1696 - http://www.ssa.gov/online/ssa-1696.html