Hospital Appeals December 6, 2012 Adrienne Mims, MD MPH Medical Director, Medicare Quality Improvement
Objectives Review process for appeals for termination of Medicare services in the hospital setting Discuss common reasons for overturns of service termination notices
Appeal Types 1. Important Message (IM) CMS-R-193 FFS and MA notice to hospital inpatients about their hospital discharge appeal rights 2. A Detailed Notice of Discharge CMS-10066 - is the second notice given from provider or plan, when the QIO review is requested in order to provide more explanation on why coverage is ending
Appeal Types (Cont d) 3. Preadmission or Admission Hospital-Issued Notice of Non-coverage (HINN 1) to determine if admission is medically necessary 4. Notice of Hospital Requested Review (HRR formerly HINN 10) - when the hospital, and not the attending physician, requests patient discharge CMS-4105-F http://www.cms.gov/medicare/medicare-general-information/bni/index.html
Hospitals Affected by this Rule Any facility providing care at the inpatient hospital level Short-term or long-term Acute or non-acute Paid through a prospective payment system or other reimbursement basis Limited to specialty care or providing a broader spectrum of services Includes critical access hospitals
Hospital Exclusions Swing beds in hospitals when used as skilled nursing beds Outpatient departments (ED, Observation Beds) Religious non-medical health care institution
Medicare Beneficiaries Covered by the Rule All hospital inpatients who are Medicare beneficiaries Beneficiaries in original Medicare Enrollees in Medicare Advantage and other Medicare health plans under MA regulations Dual eligible Beneficiaries with Medicare as a secondary payer
Procedure for Notices A completed copy of this notice to beneficiaries must be validly delivered. (Meaning = the beneficiary must be able to understand the purpose and contents of the notice in order to sign for receipt of it. The beneficiary must be able to understand that he or she may appeal the termination decision.) Beneficiary must sign and date
Procedure for Notices (Cont d) Beneficiary gets a copy and the hospital retains a copy If the notice is not valid, the QIO will notify the provider and plan and discontinue the review until a valid notice is received http://www.cms.gov/medicare/medicare-general-information/bni/hospitaldischargeappealnotices.html
Delivery of Notice Competent Beneficiary If a beneficiary is able to comprehend the notice, but either is physically unable to sign it, or needs the assistance of an interpreter to translate it or an assistive device to read or sign it, valid delivery may be achieved by documenting the use of such assistance. If the beneficiary refuses to sign the notice, the notice is still valid as long as the provider documents that the notice was given, but the beneficiary refused to sign.
Delivery of Notice Beneficiary Not Competent If the beneficiary is not competent, the notice should be made to a representative acting on behalf of the beneficiary. Hospitals should have procedures to use when the beneficiary is incapable or incompetent, and the hospital cannot obtain the signature of the beneficiary s representative through direct personal contact.
Delivery of Notice Beneficiary Not Competent (Cont d) If the hospital is unable to personally deliver the notice to a person legally acting on behalf of a beneficiary, then the hospital should telephone the representative to advise him or her when the beneficiary s services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. http://www.cms.gov/medicare/medicare-general-information/bni/index.html
Beneficiary Not Competent Valid Delivery Place a dated copy of the notice in the beneficiary's medical file and document the telephone contact to include: name of person initiating the contact, name of the representative contacted, date and time of the contact and the telephone number called. When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested.
Beneficiary Not Competent Valid Delivery The date that someone at the representative s address signs (or refuses to sign) the receipt is the date of receipt. When notices are returned by the post office, with no indication of a refusal date, then the beneficiary's liability starts on the second working day after the provider's mailing date If the representative agrees, notices may be emailed following the phone call. (HIPAA rule applies.)
Timing of Notices - Discharge Important Message Deadline to Request QIO Review Detailed Notice Deadline for QIO decision 2 calendar days following admission, unless given at pre-admission or pre-registration. A follow-up IM must be given no more than 2 calendar days before a planned discharge For same day discharge issue IM at least 4 hours before discharge Midnight of the planned discharge day No later than noon of the calendar day after notification by QIO of an appeal request QIO s normal close of business on the next calendar day after receipt of all necessary information
Timing of Notices - Admission Admission HINN and Preadmission HINN No specific time Deadline to Request QIO Review-Preadmission HINN QIO s normal close of business on the 3 rd calendar day after the beneficiary received the HINN Deadline to Request QIO Review-Admission HINN Any point during the hospital stay Deadline for QIO Decision QIO s normal close of business on 2 nd working day (Monday Friday excluding holidays) after receipt of all information needed to complete review
Timing of Notices - Discharge Hospital Requested Review When the hospital determines that the patient no longer needs inpatient care but the hospital is unable to obtain physician agreement for discharge Deadline to Request QIO Review Deadline for QIO Decision Midnight of the planned discharge day QIO s normal close of business on the 2 nd working day (Monday Friday) after the QIO receives both the request and all necessary information from the hospital
Timely Request: Liability after QIO Review QIO agrees with the notice: Liability for continued services begins at noon of the day after the QIO notifies the beneficiary QIO disagrees with the notice: No beneficiary liability for continued care (other than co-insurance and deductibles) Failure of the hospital to give needed information may result in a decision based on evidence at hand or a delay in making the decision.
Untimely Requests: Liability During QIO Review Beneficiaries who do not request a review and remain in the hospital past the d/c date: May request QIO review at any time May be charged for any services provided after the discharge date Will be refunded any funds collected, if the QIO finds for the patient Beneficiaries who miss the deadline and leave the hospital continue to have the right to request a QIO review within 30 calendar days of the date of discharge
Reconsiderations for Hospital Appeals Insurer Patient Status Re-reviewer FFS Patient still an inpatient QIO FFS Medicare Advantage Medicare Advantage Patient has been discharged Patient still an inpatient Patient has been discharged Administrative Law Judge, Medicare Appeals Council or federal court QIO Refer to Medicare Health Plan for information on appeals rights
Medical Records Responsibility FFS the hospital must provide the medical records MA the MA plan or hospital (by delegation) must provide the medical records Missing, incomplete or Illegible records QIO decides whether to proceed with available information or defer review until additional information is received but the deadline for QIO review does not change and the hospital may be liable if covered services continue past the planned discharge date ( 7370.3)
Appeals Process Plan/Facility determines service end date Notice issued and signed Patient calls requesting appeal Review Nurse (RN) contacts facility/plan PR decision faxed to RN RN faxes record to Physician Reviewer (PR) RN confirms records are complete/ legible & valid Records faxed by facility/plan RN notifies facility/ Plan/patient by phone RN mails & faxes notification letter Patient may request review of decision Review process repeated with second PR
Records Needed for Review Processing Signed and dated Notice (IM or HINN) Detailed Notice (if an IM) Face Sheet H&P Orders - must include a discharge order for IM; an admission order for HINN MD progress notes PT, OT, ST notes Lab, X-ray results Case Management notes / discharge planning Consultations / Evaluations Attending MD name, phone number (cell, pager or office)
Role of Physician Reviewer Important Message Admission was appropriate Patient s condition is stable enough for discharge Discharge consistent with patient no longer needing continued acute inpatient hospital care HINN Patient s condition can be safely treated as an outpatient This admission is for a service excluded by Medicare Hospital Requested Review Admission was appropriate Patient s condition is stable enough for discharge Discharge planning complete and appropriate