Delivering the Medicare Important Message

Education, documentation will help

If your hospital is having difficulty complying with the new Medicare rule for notifying patients of their right to appeal their discharge, you're not alone.

"It's difficult to deliver the message and everybody is struggling with the new components," says Cassandra Barnes, RN, MS, CCM, senior consultant for case management at Pershing Yoakley and Associates' Atlanta office.

The new rule, which went into effect July 2, updates a previous regulation establishing how hospitals must notify Medicare beneficiaries of their right to appeal their discharge, their financial responsibility, and how to appeal a hospital discharge.

The rule applies to traditional Medicare beneficiaries, beneficiaries enrolled in Medicare Advantage programs, and other Medicare health plans that are subject to Medicare regulations.

The Important Message (IM) from Medicare must be delivered within two calendar days of inpatient admission and must be signed by the beneficiary or his or her representative and dated and a copy must be given to that person. If a patient stays more than two days in the hospital, he or she must receive a copy of the original signed form within two calendar days of discharge.

The Centers for Medicare & Medicaid Services (CMS) allows hospitals to issue the IM at preadmission but not more than seven calendar days before the admission.

Medicare beneficiaries who are admitted to outpatient observation can be given the IM when they are admitted if they are advised of the difference between observation and inpatient admission.

If the patient's status is converted to an inpatient level of care, the IM should be delivered within two days of when the level of care changes.

If a patient disagrees with the discharge and requests a review by the Quality Improvement Organization (QIO) following the hospital's or Medicare's determination that inpatient care is no longer necessary, the hospital must give the patient a more detailed notice that further explains the appeals process. This notice should be delivered as soon as the QIO notifies the hospital that a Medicare beneficiary has requested a QIO review.

Historically, patient registration staff have delivered the initial Important Message from Medicare, but just handing patients a notice and getting their signature doesn't meet the intent of the law, Barnes points out.

"The whole intent of the Important Message is to let Medicare beneficiaries know that they have the right to appeal their discharge date if they disagree with the physician. This means that all hospital staff involved in the delivery of the Important Message must make sure that patients understand what they are signing," she says.

She recommends that hospitals create a script for the admissions staff, making sure they explain what the notice of appeal means in order to meet the intention of the requirement and maintain continuity in the delivery process.

"We tell the admissions staff to make sure the patients understand that if they are in the hospital more than two days, they'll get another copy. Otherwise, they may be confused when they get the second notice," Barnes says.

When is the best time?

At Weatherford Regional Medical Center in Weatherford, TX, patients are given the Important Message from Medicare when they go through registration. Then the case managers discuss the document with the patients and family members and make sure they understand it when they make their initial assessment, says Lyn Clark, RN, BSN, MHA, director of case management for the 99-bed hospital.

"Sometimes patients coming into the hospital are disoriented and put it with their other papers. Admission may not be the right time to make sure they understand it. That's why we cover it when we complete our initial assessment," Clark adds.

The case management secretary at Southern Ocean County Hospital in Manahawkin, NJ, is responsible for making sure that Medicare patients receive the Important Message in a timely manner. She goes on every unit each morning and gives the document to the new patients.

If the patient doesn't seem to understand the document, she notifies the case manager, who talks to the patient about the document and contacts the next of kin or person with power of attorney for the patient, says Marilyn Butler, RN, MSN, CCM, director of case management.

Hospitals should take an interdisciplinary approach to ensuring that the patients get the Important Message as specified by the regulation, Barnes says.

"In most organizations, case managers don't work 24 hours a day, seven days a week. Hospitals must make sure that someone delivers the Important Message when case management is not available," she says.

Make sure that all hospital staff who may be involved in delivering the Important Message can accurately inform beneficiaries of their appeal rights and answer questions.

"Ultimately, the entire organization is responsible for becoming compliant with this process," adds Lorraine Larrance, BSN, MHSA, CPHQ, CCM, manager with Pershing Yoakley & Associates

Schedule follow up

She suggests setting up a mechanism to ensure that the follow-up copy of the Important Message is delivered on weekends and holidays or other times when the case manager is not available and assign responsibility to the charge nurse, house supervisor, discharging nurse or other staff member.

Any staff who may be responsible for delivering the Important Message should receive formal education on the process and what is required. The same formal education should be part of orientation for new employees, Larrance adds.

"Clinical conditions may change drastically during the day. If the doctor says a patient can be discharged at 5 p.m. on Sunday, Medicare recognizes that the patient recovered sooner than anticipated but that doesn't eliminate the necessity to deliver the Important Message. It's OK to give patients the Important Message on the day of discharge. However, there should be a four-hour window between the time the Important Message is delivered and discharge to give the patient a chance to appeal," Barnes says.

At Weatherford Regional Medical Center, nurses and house supervisors are trained to deliver the notice if the discharge, takes place sooner than anticipated and the case manager is not on duty.

In the event that a patient wants to request a review by the QIO, someone on the staff should know what steps the hospital should take, Larrance says. This could be charge nurses, house supervisors, case managers, social workers, or utilization review nurses, she says.

Someone on the evening, night, and weekend shifts should be educated on the process, she says.

Help staff facilitate review

Larrance suggests preparing a packet of information with specific instructions on copying/faxing the medical records, QIO contact numbers, designated contact persons for the QIO, required turnaround times, and other information that will help staff facilitate the QIO review process.

Making sure that patients with longer lengths of stay receive the Important Notice two days before discharge has proved to be a challenge, Barnes says.

"Some organizations have chosen just to deliver the notice every couple of days so they won't be noncompliant. This is really confusing to patients and should not be the normal practice," she adds.

Hospitals can ensure that they are compliant and not issuing notices unnecessarily by proactively identifying potential discharges, she adds. Interdisciplinary team meetings, bed control meetings, and hospital rounds are all ways to capture potential discharges.

"If you watch patients' clinical progress, there is a point at which you can recognize that the patient is almost ready for discharge. Taking this proactive step can help hospitals comply," Barnes says.

At Weatherford, the case manager puts a sticker on the front of the chart noting the date that the Important Message has been delivered and alerting staff that the patient needs to receive another copy if the length of stay exceeds two days.

"We look at the charts every day to see what the anticipated discharge will be and make sure the Important Message is delivered within the specified time frame," Clark says.

At Southern Ocean County Hospital, the case management secretary keeps a spreadsheet showing who has received the document and communicates with the case managers on each unit every morning to find out which patients may be discharged within the next few days — then makes sure that they receive a copy of the form.

Documenting that the Important Message was delivered is important, Larrance points out. She suggests creating an admissions checklist so that patient registration staff can document that Medicare beneficiaries admitted to inpatient or outpatient observation status receive the initial Important Message.

Discharge planning worksheets should provide documentation of the discharge planning activities, including anticipated discharge dates. They should be updated every two to four days, she adds.

Larrance suggests monitoring compliance with all aspects of the rule at least every three months until trends are stable and the compliance officer has determined that compliance with the rule has been achieved. Include the results of the compliance audits in your process improvement initiatives, she adds.

(Editor's note: For more information, contact Marilyn Butler, RN, MSN, CCM, director of case management, Southern Ocean County Hospital, e-mail: mbutler@soch.com; Lyn Clark, RN, BSN, MHA, director of case management, Weatherford Regional Medical Center, e-mail: zlaclark@hotmail.com; Lorraine Larrance BSN, MHSA, CPHQ, CCM, manager with Pershing Yoakley & Associates, e-mail: llarrance@pyapc.com.)