More than a Century of Legal Experience

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1 Advanced Beneficiary Notice (ABN) and Hospital Issued Notice of Non Coverage(HINN): To Issue, or Not to Issue an ABN or HINN July 30, 2013 Presented by: Jennifer McManis More than a Century of Legal Experience This document is the property of Crowley Fleck, PLLP and is not to be reproduced or distributed without permission. Agenda Benefit & Limit on Liability Provisions Benefit Advanced Beneficiary Notice & Notice of Non-Coverage Categorical & Technical Denials Medicare HMOs Triggering Events Initiation of Service Reduction in Service Termination of Service Proper Notice Advanced Beneficiary Notice Standards Timeliness Delivery Routine Notice Reason for Predicting Denial Settings Notice of Medicare Non-Coverage Expedited Determination Notice & ABNs Timeliness Delivery Forms Outpatient Inpatient Extended Care (SNF) Services Resources Advanced Beneficiary Notice & Notice of Noncoverage Resources ABN & HINN Analysis Tool 1

2 Think Covered Benefit Limit on Liability (LOL) Provisions Limit on Liability Provisions Protect beneficiaries from liability excluded from coverage Provision Does Not Apply to members of a Medicare HMO 2

3 Advanced Beneficiary Notice is a Process not a Form Use form based on the benefit & service that the patient is receiving ABN & Notice of Non-Coverage are separate processes ABN Process Required Think Benefit Medically Unnecessary (LCD & NCD) Pneumococcal, influenza, and Hepatitis B vaccine & administration frequency/illness Research & Experimental Treatment Screening services performed more frequently Custodial Care Medically Unnecessary Inpatient Services Home Health Services Hospice Services 3

4 ABN Process Voluntary No-Benefit Categorical Denials Personal comfort items Most vaccinations Routine eye care and examination Hearing aids & hearing examinations Cosmetic surgery Orthopedic shoes and foot supports Dental care & dentures Routine Foot Care and flat foot care ABN Process Voluntary Benefit-Coverage Requirement Not Met Technical Denials Self Administered ed Drugs 3 Day qualifying stay not met for SNF 30 Days after discharge to SNF Home Health services not ordered on a plan of treatment Items that do not meet the definition of DME Ambulance services denied because transportation by other means is not contraindicated Inpatient Only Procedure Performed in an Outpatient Setting Parenteral or nutrition therapy and does not qualify for the prosthetic device Items do not meet the definition of DME LOL Provisions Triggering g Events 4

5 Triggering Events Initiation of Service Beginning of Service, start of a plan of care or beginning of treatment and you believe the services will not be covered Example: Patient asks her physician for an EKG because her sister was diagnosed with atrial fibrillation. No reason that warrants medical necessity of an EKG but insists on having one; Example: Radiology services not related to an inpatient stay and is known to be noncovered Reduction of Service Decrease in a component of care, i.e. frequency, duration, etc Example: If a reduction in service occurs but the patient wants to continue to receive the care that is no longer considered medically reasonable and necessary, the patient must be notified prior to the delivery of the non-covered care Termination Services are terminated or discontinued and the patient wants to continue receiving i care that is no longer medically reasonable and necessary Example: Outpatient therapy that is no longer needed Example: Inpatient discharge order written and patient does not want to leave Triggering Events 5

6 Standards Proper Notice Documents Timeliness Effective Delivery Routine Notice Prohibition Standards for Emergency Situationsti Reason For Predicting Denial Proper Notice Documents Written Notice Issue each time Timely Readability 12 point font No italics Do not block shade/highlight text Insertions in forms must be typed, printed, or legible Specificity, Delivery, Receipt Written in lay language Comprehended by the person who signed Timeliness Notified in advance Take place before prep for a procedure 6

7 Effective Delivery Defective Notice Unreadable, illegible, individual incapable of understand, given under emergency, considered a routine notice Simply a statement that medicare will not pay Delivered more than one year before services Telephone Notice Follow up written notice or delivered in person Capable Recipient Confused,g great duress, comatose, illiterate, hearing impaired Refusals Note Refusal on form Authorized to sign Understand who may sign Routine Notice Prohibition Issuing an ABN when there is no specific reason to believe Medicare will not pay Generic Routine ABN which do no more than state that Medicare denial is possible Valid ABN must state the actual reason Blanket Exception to Routine Notice Prohibition Services which are always denied for medical necessity Medicare never pays for this item or service Experimental Items and Services Frequency of Preventive Services 7

8 Triggering Events Notice of Non-Coverage Standards Notice of Non-Coverage Standards Notice of Non-Coverage: Hospitals Given within 2 days of admission and no more than 2 days prior to discharge Applies to Medicare & Medicare Advantage Patient has right to request an expedited review by the QIO HINN is given if the patient decides to continue to have services once the decision to discharge has been made Notice of Non-Coverage: SNFs, HHAs, Hospice, CORFs Form CMS Given two days prior to the termination/end of services Deliver to all eligible even if they agree with the termination of services Applies to Medicare & Medicare Advantage Combined to one notice ABN is given if the patient decides to continue with services once the decision has been made Do not give when benefits are exhausted or reduced Patient has right request an expedited review by the QIO; Form CMS If requested deliver by close of business day they day you are notified Do not routinely give notice at the time services begin unless the service is expected to last fewer than two days Timely Notification: 2 days prior, written or telephone contact 8

9 Triggering Events Notice of Non-Coverage Standards Forms FORMS The issuance of a Notice of Non-Coverage does not always result in initiating the ABN process Advanced Beneficiary Notice ABNs HINNs Notices of Non-Coverage Notices of Non-Coverage Hospital Issued SNFs, HHAs, Hospice, & CORFs Does not always result in issuing an ABN/HINN 9

10 FORMS ABN, Hospital Issued Notices of Noncoverage (HINN), Notice of Medicare Non-Coverage (NOMNC), & Detailed Explanation of Non-Coverage (DEONC) Outpatient Inpatient Skilled Nursing Facility: Part A Home Health DME Providers Skilled Nursing Facility: Part B Hospice Outpatient Inpatient Extended Care (SNF) Services ABN Form CMS-R- 131 Important Message from Medicare HINN 10: HRR HINN 11: Non-covered Service SNF Part A Services ABN Form CMS or Denial Letters SNF Part B Services ABN Form CMS-R-131 FORMS ABN, HINNs, NOMNC,& DENC Detailed Notice of Discharge HINN 1: Preadmission HINN 12: Continued Stay Termination Notice NOMNC CMS PT Request Review of Termination DENC CMS HINN 1: Preadmission/* Letter 9(a)-(c) HINN 12: Continued Stay/*Letters 3-4;6-7 *Letters 2-9 Retired 10

11 Inpatient HINN 1: Preadmission Issued: before providing noncovered services Physician Concurrence not required Effective: At admission- 3:00pm or earlier HINN 11: Non-covered Service Issued: during a covered inpatient stay prior to the performance of a diagnostic or therapeutic service that is excluded from coverage as medically unnecessary Effective: Immediately HINN 12:Continued Stay Issued: to a patient who chooses to remain in the hospital beyond the hospital determined discharge date. Effective: Depends if the patient requests an Expedited Review HINN 10:Hospital Requested Review (HRR) Issued: when hospital determines care is not needed but is unable to obtain agreement of the physician Effective: Noon the Day after QIO notification Extended Care (SNF) Services The differentiation of when to use a HINN is most difficult for swing beds HINN Do not use once skilled care has begun in Swing Beds HINN Use when a patient changes from a hospital level of care to a skilled level l or non-skilled kll level of care 11

12 Extended Care (SNF) Services SNF Notice of Noncoverage Use when covered skilled care is ending SNF ABN Use when there is a reduction in service Use when skilled care is ending Extended (SNF) Services HINN 1: Preadmission/*Letter 9(a)-(c_ Issued: before providing non-covered NF services provided in a swing bed Physician Concurrence not required Effective: At admission if given before 3:00pm SNF ABN Issued: to patients in a swing bed when services will be reduced or terminated and patient wants to continue with services Effective: Date Issued HINN12: Continued Stay/*Letters 3-4; 6-7 Issued: to a patient who chooses to remain in the hospital beyond the hospital determined discharge date Notice Content: Acute Care Inpatient Hospital care not covered Effective: Depends if the patient requests an Expedited Review Detailed Explanation of Non-Coverage (DENC) Issued: to patient who received a NOMNC and has requested a DENC Provide DENC by close of business day Notice of Medicare Non-Coverage & SNF ABN Issued: two days before the termination of services Patient may request an Expedited Determination Patient may decide to continue with services; issue a SNF ABN Letters 2-9 Retired 12

13 Risk Areas Blanket ABN Simply states may not pay Giving ABN for all items Having patient sign a blank ABN Incorrect Form Outpatient Notice used for Inpatient Setting Medicaid Medical record supports patient is ready to be discharged or does not need skilled care Service ordered that is unrelated and does not meet diagnosis requirements Signed but not maintained, unable to locate ABN or HINN Summary Triggering Event Notice of Non-Coverage Standards Forms Resources: ABN & Notice of Non Coverage Resources ABN/HINN Analysis Tool 13

14 This document is the property of Crowley Fleck, PLLP and is not to be reproduced or distributed without permission. Contact Information Jennifer McManis