Documentation is the key when issuing HINNs

Noncompliance could lead to future repercussions

If you aren't complying with the Centers for Medicare & Medicaid Services (CMS) requirements for issuing Hospital Issued Notices of Noncoverage (HINNs) and documenting them well, your hospital could face severe repercussions down the road, according to Jackie Birmingham, RN, MS, CMAC, vice president of regulatory monitoring for Curaspan Health Group, a Newton, MA, health care technology and services firm.

"Hospitals have to inoculate themselves against denials by doing the right thing and documenting it. Case managers should be conscious of the fact that HINNs are not just a pain in the neck. Not following the CMS guidelines could affect the hospital's reimbursement, increase the risk of audits by the Recovery Audit Contractors and others, and impede the patient's ability to understand what his or her rights are and what the hospital expects of the patient," she adds.

Hospitals are required to deliver HINNs to beneficiaries prior to admission, at admission or at any point in the stay when the hospital determines that the care the patient is receiving or is about to receive is not covered because it's not medically necessary, is not delivered in the most appropriate setting, or is custodial in nature.

"HINNs allow hospitals to build a paper trail showing that the hospital did everything possible to ensure that the patient was transferred to an appropriate level of care. Then, when the time comes to appeal a RAC denial, the hospital will be able to show that there was a valid discharge plan in place and the chances for a successful appeal are better," she says.

As Medicare rolls out the Recovery Audit Contractor (RAC) program nationwide, the RACs are going to be tracking patterns of denials and carefully scrutinizing hospitals for compliance, Birmingham points out.

"Failure to deliver a HINN and document it can have a real snowball effect down the road. If hospitals are audited for continued stays when a patient does not meet medical necessity criteria and they have no proof that they made an effort to discharge the patient to another level of care, the claim can be denied and the denial upheld," Birmingham says.

In addition, if the RAC finds the hospital has a pattern of keeping patients for three days, even though they didn't meet medical necessity, then discharging them to a nursing home, the hospital must have evidence it was trying to discharge the patient or it may face fraud charges, she adds.

"CMS, the RACs, and the Department of Justice all share information," she says.

This makes it even more important for hospitals to have documentation that the hospital determined that the service was appropriate in another setting, that it was available, and that the patient was given a choice of providers, she says.

"In the past, when patients needed post-acute care, case managers would call the provider and wait for a response. Often several days would elapse. Having an electronic tool to make and document referrals is important because there is instantaneous communication between the hospital and the post-acute provider. This ensures that the hospital can issue the HINN in a timely manner and document it," she says.

CMS is specific about when HINNs 10, 11, and 12 need to be applied and includes specific language on its web site, Birmingham adds.

"The most important thing is for hospitals to have the ability to retrieve documentation that there was a valid discharge plan in place. Having good documentation is worth its weight in gold when it comes to appealing denials," she adds.

The HINN 10, also known as the Notice of Hospital Requested Review, should be given to patients when the hospital requests a QIO review because the attending physician does not agree with a discharge decision.

Before the HINN 10 is issued, the case manager should determine that the services the patient needs can be safely delivered in another setting and that an appropriate bed is available, then talk to the family members and physician, Birmingham says.

"If a hospital has a system in place so they can document that a referral was sent to multiple post-acute providers and that the services the patient needs are available in another setting, it can show the QIO that their request is valid," she says.

The HINN 10 should be given only when the treating physician does not write the discharge order, Birmingham says.

The hospital's utilization review committee, which must be chaired by a physician, must agree to requesting a QIO review of a continued stay, Birmingham points out.

"The case managers are not in this all by themselves. Their job is to get a plan in place and document it and have their physician advisor concur with them," she adds.

The HINN 12 should be issued any time the patient is staying beyond medical necessity criteria to inform patients of their potential liability for a noncovered continued stay because the care won't be delivered in the most appropriate setting.

"HINN 12 is intended for instances when a patient needs a service — such as IV therapy, physical therapy, or occupational therapy — and can get it in the hospital but it's more appropriate in another setting. The only way a hospital can prove that the service is available in another setting is to send a referral to a post-acute provider, have them review the patient's clinical needs and determine that they can deliver that type and intensity of care," Birmingham says.

Hospitals must explain in plain language the reason the hospital believes the stay will not be covered by Medicare and include an estimate of the daily cost of care if the patient stays.

Some case managers are reluctant to give patients the HINN 12 because they know many patients can't afford to pay for their care out of their own pocket, Birmingham says.

"Regulations mandate that hospitals will deliver the HINN 12 at the appropriate time. If a case manager lets the patient and family control how long they will stay, they aren't doing them a favor, and down the road, the financial ramifications could be really bad," she adds.

HINN 11 is to be used for noncovered items and services provided during an otherwise covered stay and should be issued by the business office, Birmingham says.

Case management departments should have a process in place for alerting the business office whenever a physician orders a procedure that can be delivered in another setting, she says.

HINN 11 was instituted in 2006 and continues to cause confusion. It is the most intricate of the HINN notices, Birmingham adds.

"Case managers should monitor the professional services rendered and work with the physician advisors to determine whether or not a HINN 11 should be issued," she says.

Hospitals may opt not to charge patients for the noncovered service and should issue the HINN 11 only when they plan to charge the patients, according to CMS regulations.

A hospital representative should go over the HINN 11 with the patients to make sure they understand it before signing it and should give a copy to the patient and to the attending physician.

Other types of notices that the hospital case manager should be aware of are the Advanced Beneficiary Notice (ABN) and the Pre-admission/Admission notice, Birmingham says.

These types of HINNs are given before a stay that is entirely noncovered or a service that may not be covered. These notify the patient that he or she may be liable for the service or hospital stay, Birmingham says.

HINNs may be used when the patient has been receiving observation services and doesn't want to go home, Birmingham says.

The document tells the patient that Medicare is not likely to pay for the stay because it is not medically necessary or because the service can be delivered in another setting and notifies the patient that he or she can appeal to the QIO.

(For more information, contact: Jackie Birmingham, RN, MS, CMAC, vice president of regulatory monitoring for Curaspan Health Group, e-mail: For more information on the HINNs, including sample notification letters, visit the CMS web site at: