Discharge Planning Advisor

Collaboration key in new discharge notice rule

Expands patients' rights to appeal discharge

Beginning July 2, hospitals must begin a new process of notifying Medicare beneficiaries of their discharge appeal rights.

The final rule, Notification of Hospital Discharge Appeal Rights issued by the Centers for Medicare & Medicaid Services (CMS), requires hospitals to give patients a revised "Important Message from Medicare" (IM) stating their right to appeal their discharge and to issue a "Detailed Notice of Discharge" as necessary.

The final rule requires patients receive an initial "Important Message" within two calendar days of admission and a signed copy of the notice within 48 hours of their discharge, if their length of stay is longer than two days.

Medicare beneficiaries' right to appeal

The rule, which applies to both original Medicare beneficiaries and those who are enrolled in Medicare health plans, establishes how hospitals must notify Medicare beneficiaries of their right to appeal, their financial responsibility, and how to appeal a hospital discharge.

If patients request a review by the quality improvement organization (QIO) following the hospital's determination that inpatient care is no longer necessary, the hospital must give the patient a "Detailed Notice of Discharge" no later than noon on the day the QIO notifies the hospital of the beneficiary's request for a QIO review.

"This process is an expansion of previous dictates regarding a Medicare patient's right to appeal his or her discharge. For some time, CMS has required hospitals provide Medicare beneficiaries with the Important Message from Medicare" at the time of admission. Now CMS is requiring that patients who have an inpatient length of stay of longer than two days also receive a copy of the IM within two days of discharge as a reminder of their rights to appeal the discharge decision," says Lorraine Larrance, BSN, MHSA, CPHQ, CCM, manager with Pershing Yoakley & Associates, a health care consulting firm with offices in Knoxville, TN; Atlanta; Tampa, FL; and Charlotte, NC.

Interdisciplinary collaboration is going to be key in assuring compliance with the new rule, points out Cassandra Barnes, RN, MS, CCM, senior consultant for case management at Pershing Yoakley & Associates' Atlanta office.

How to comply

"Hospitals must formalize how they identify potential discharges in order to be compliant with the rule. Case managers are good at anticipating the discharge date. What hospitals need to do is to determine who will deliver a copy of the discharge appeal notice within the 48-hour window," she says.

Barnes suggests developing a tickler system to remind staff that patients must receive another copy of the IM form two days before discharge and a way of documenting in the medical record that the patients received the additional notice.

"This form is like any other hospital form that stays part of the medical records. If Medicare comes in and audits the charts, the documentation should be there," Barnes says.

Hospitals should already have procedures in place for giving Medicare beneficiaries a copy of their right to appeal notice on admission, Larrance adds.

Look at which disciplines could be involved in making sure that the patient receives a copy of the notice before discharge, she suggests. "This is likely to be an interdisciplinary effort that may involve the patient access staff, nursing, and physicians as well as case managers," Larrance says.

For some time, hospitals have had to give patients the notification that they can appeal their discharge and that notice will be sufficient for patients whose length of stay is two days or less, Barnes points out.

On the other hand, in cases when the delivery of the initial "Important Message" occurs more than two days before discharge, hospitals will need to deliver a follow-up copy of the signed notice to the beneficiary as soon as possible prior to discharge but no more than two days before, she adds.

Notifying observation patients

One challenge will be to ensure that patients who are initially placed in observation status receive the form when they are admitted as an inpatient.

"One way of meeting the criteria for observation patients who are later converted to inpatient status might be to give the IM notice to all Medicare patients whether they are in observation or inpatient status. This assures that they will receive the IM within two calendar days of the actual admission to the inpatient level of care," Larrance says.

An interdisciplinary approach to the process will be necessary in order for a hospital to comply with the rule, she adds.

"Since the entry point for most hospital patients, such as the emergency department or patient registration area, is staffed by clerks who are not medically trained professionals, system-wide education should be provided to everyone involved in the process. All staff should be trained to educate patients on the intent of the IM notification document," Larrance says.

When patients are admitted, the original copy of the notice should go into the medical record. When the decision is made to discharge a patient, a nurse or case manager should deliver a copy of the notice within two days of the discharge date, to the patient to remind them of their right to appeal their discharge, Larrance says.

"Case managers are in the best position to anticipate the discharge date, based on the patient's diagnosis and other factors and are crucial in assuring that the requirements of the final rule are met. Open communication between the case manager, the nursing staff, and the physician will be required to make this a seamless process," Larrance says.

Medicare has stated that the intent of the "Important Message" is to make sure that patients understand they have a right to appeal their discharge and to understand the appeals process.

"Patients often are very sick when they come in or they may not understand everything they sign. Because of these and other circumstances, CMS wants to make sure that the patients understand that they can appeal their discharge and the second notice should serve as a reminder of this. Just having them sign the paper doesn't meet the intent of the Important Message notification," Larrance adds.

(For more information, contact Lorraine Larrance, BSN, MHSA, CPHQ, CCM, manager with Pershing Yoakley & Associates, e-mail Llarrance@pyapc.com. Cassandra Barnes, RN, MS, CCM, senior consultant for case management with Pershing Yoakley & Associates, e-mail: cbarnes@pyapc.com.)