Notify patients of financial responsibility if they don't meet Medicare criteria

HINNs should be used when patients no longer qualify for acute care

Changes in the notifications that hospitals must give Medicare patients about their pending discharge are making discharge planning and careful documentation more important than ever before.

In addition to making changes in the delivery of the Important Message from Medicare, which includes notifying patients of their right to request a review of their discharge, the Centers for Medicare & Medicaid Services (CMS) has revamped its set of Hospital-Issued Notices of Noncoverage (HINNs), which inform patients of any potential financial liability if they receive services that Medicare does not cover.

The process of a review/appeal includes issuing a "detailed notice," which lists, in language patients can understand, the reason their doctor has discharged them and the reasons that the patient no longer meets Medicare criteria, says Jackie Birmingham, RN, MS, vice president of professional services at CuraSpan Inc., a Newton, MA, health care technology and services firm.

The Important Message must be given to patients within two days of admission and again within two days of discharge. "The 'detailed notice' process in the July 2, 2007, notification rule is more important to case managers than the Important Message letter. The detailed notice starts the process of identifying that the patient is at an acute level of care and what to do next if the patient is considered by the Quality Improvement Organization [QIO] to be ready for discharge," she says.

The next step in the process is deciding whether the patient should be given a HINN, notifying him or her of potential financial liability for the hospital's services, Birmingham adds.

"The whole process has changed. I made a chart showing all the new forms so we will be able to determine which form to give when," says Roxana Ballinger, RN, CCM, director of care management at Regional Medical Center in Chesapeake, VA.

Hospital-Issued Notices of Noncoverage are notices of financial liability that are to be used by hospitals when the patient is no longer deemed eligible for acute care by CMS and there is some question about financial liability, Birmingham says. These include services that are not medically necessary, that are custodial in nature, or services that can be provided in another level of care, such as at home with home health or in a skilled nursing facility.

"Patients have a right to be informed of their pending discharge and can request a review by the QIO if they or their representative have a concern and they also have a right to be informed of any potential financial liability should they be receiving services which Medicare does not cover," she adds.

At the same time, hospitals have a right to be paid for the services that are medically necessary and that makes it imperative to document that patients have been informed of discharge plans and that they have been given the HINNs, says Birmingham.

"Hospitals must have proof that patients have been informed of any potential financial liability should they be receiving services which Medicare does not cover. Case managers should document their discharge planning efforts and conversations with the patients and family. In addition, a copy of any HINN given to a patient must be kept in the patient chart," she adds.

In order to be sure that the patient is informed of potential liability, CMS has a set of HINNs that can be used in various situations.

HINNs most likely to be used by CMs

According to the instructions released by the Centers for Medicare & Medicaid Services, Birmingham suggests that case managers are most likely to use the following HINNs:

• Preadmission or Admission Hospital-Issued Notice of Noncoverage replaces HINNS 1 and 9 and is to be used prior to a noncovered stay.

The hospital should notify the patient that Medicare is not likely to pay for the admission because it's not considered to be medically necessary or it could be furnished safely in another setting.

• Hospital-Requested Review (HRR) notifies patients that the hospital has determined that the patient no longer meets Medicare criteria for a continued stay because the services are no longer medically necessary but the physician disagrees. The HRR notifies the patient that the hospital is asking the QIO to review the case and that the QIO will be contacting the patient to discuss the case.

• HINN-11 (Noncovered Services During a Covered Stay) notifies patients of services that may not be covered by Medicare during an otherwise covered stay.

Hospitals should issue a HINN-11 when Medicare coverage policies state that a diagnostic or therapeutic item or a service is not covered, based on medical necessity, but the patient still requires continued hospital inpatient care. The item or service must not be bundled into payment or treatment for the diagnosis that justifies the inpatient stay.

HINN-11 certifies the patient's consent to accept financial liability for the noncovered procedure or procedures. Hospitals must give a copy to the patient, his or her physician, and to the QIO upon request

The HINN-12, Noncovered Continued Stay notice, is a new notice, which became effective in July 2007, which notifies patients that the hospital believes Medicare may not continue to pay for their hospital stay beginning on a certain date. The notice states the reason in easy-to-understand language, and includes the estimated cost of the patient's stay, beginning from the date of noncoverage. The notice also encourages the patient to discuss his or her pending discharge with the physician.

Hospitals may consider issuing the HINN-12 when a patient requests a review of his or her discharge by the QIO and the QIO agrees with the discharge, Birmingham says.

This HINN should be issued only if there is some concern on the part of the hospital that the patient may be financially liable for his or her continued stay after the review process has been completed, she says.

"When you give someone who is appealing their discharge the detailed notice, it's not a bad idea to give them the HINN-12 because it spells out so simply if they have to be responsible for the bill," Ballinger adds.

Knowing when to issue the HINN-12 gets complicated when patients are being discharged to a lower level of care, Birmingham points out.

'Not as straightforward as it seems'

"The HINN-12 is not as straightforward as it seems. Case managers have to use their judgment according to the individual situation and coordinate the process with the utilization review committee to determine when to issue the HINN-12," Birmingham says. For instance, if a patient no longer meets hospital level of care criteria but there is not a bed that is appropriate for the patient available at a lower level of care, the hospital probably shouldn't issue a HINN-12 because the patient isn't at fault.

Sample HINN Notices

However, if a bed is available and the patient or family refuses to go and the reason for the refusal is reviewed by the utilization review director, the HINN may be issued and the hospital can charge the patient for the subsequent days.

"The issue gets difficult for discharge planners when the patient has been in the hospital only two days but needs a three-day stay to be eligible for extended-care benefits in a skilled nursing facility, or when the case manager finds an appropriate bed but the family says it's too far away," Birmingham says.

When the QIO steps in

If a patient or family requests a review in hopes of delaying the discharge so the patient is eligible for the "extended-care benefit" and the QIO determines that the hospital stay was not medically necessary at the time of the request for the review, the day will not count toward the three-day requirement for coverage, Birmingham points out.

"Case managers are in a pivotal place when working with patients and families in helping sort out what is covered and what is not. The financial interest of the patient exists and the financial interests of the hospital must be considered. Case managers must take the time to learn the rules for coverage, work closely with the physician advisors and the QIO so that they can be advocates for patients and to make sure the hospital gets paid appropriately," she adds.

(For more information, contact Jackie Birmingham, RN, MS, vice president of professional services, CuraSpan Inc., e-mail: jackiebirmingham@sbcglobal.net.)