Access managers blast Medicare appeal form

Join the how-to-do-it debate

A Medicare form that’s been around for a while is getting new attention from the Health Care Financing Administration (HCFA) and causing headaches for access managers who say distributing it is an unnecessary hardship.

The Notice of Discharge and Medicare Appeal Rights, formerly known as the Notice of Non-coverage, is designed to give Medicare managed care patients the same rights to appeal a discharge as traditional Medicare patients, but the effort is misguided, says Jack Duffy, FHFMA, corporate director for patient financial services at ScrippsHealth in San Diego. "It’s the worst thing that ever happened. It’s like an informed consent, but I know these patients. They have a limited comprehension of legalese."

Within his organization, Duffy notes, access personnel "are saying nurses have to [distribute the form], and nurses are saying access should do it." If the signed form has to be stored on the patient’s chart and copied every time the chart is copied, that raises another logistical concern, he adds.

The notice has been part of HCFA regulations for years but had been "largely ignored for a long time," says Kathy Warren, MS, chief operating officer of Qualidigm, a quality improvement organization in Milltown, CT. "The statement in the regulations basically said that a managed care plan had to give patients notice within so many hours of discharge that they could appeal that discharge if they thought they were being discharged too soon."

About a year ago, "probably because one of the advocacy groups noted that it was being ignored," the regulation was resurrected, Warren says, and became a topic of discussion. "HCFA said it had to be done; managed care plans started looking into how it could be done, and people were struggling with how it had to be done."

Managed care plans don’t have someone on site at hospitals to present the form to patients, she adds, so the questions became, "Who is going to do it?" and "How will it be done?"

The most illogical thing about the notice, points out Scripps access director Mollie Drake, MBA, is that it’s supposed to be presented even to patients who are in full agreement with their discharge. "It states that after this date, the insurance company will not pay the hospital bill. Elderly patients may see this and think the two-day stay they’ve just had is not paid for.

"There is also a real logistical concern," Drake adds. If access services is charged with distributing the form, "this requires that the nursing floor contact access and let them know the patient is being discharged. Then the access representative must look to see if the patient being discharged [is a Medicare HMO patient] and, if so, fill out a form, run to the patient’s room, discuss it with the patient, and get a signature on the form."

With luck, she adds, the patient has been informed of the discharge, but that may not be the case. "They may not know they’ve been discharged yet, so we have to make sure we’re not the ones giving that notice.

"It’s a horrible procedure that will cause a lot of confusion," Drake says. "I could understand presenting the form to a patient who is disputing the discharge. Even with a regular Medicare patient, we only do this if the patient disagrees with the discharge, so we are going beyond what we do for a regular Medicare patient."

Warren’s understanding, she says, is "HCFA is not necessarily enforcing it," but discussions continue on how to implement the regulation.

Despite repeated calls, Hospital Access Management could not get a response from HCFA on the Medicare notice. A Feb. 11, 1999, operational policy letter, currently posted on the HCFA Web site (, addresses the issue. The letter states that "after consultation with beneficiary, managed care plan, and provider communities, [HCFA] revised the model language for the Notice of Non-coverage and [has] changed its name to reflect a more beneficiary friendly’ notice."

The letter also says, however, that there are "still many unanswered questions regarding proposed changes to our policies for these notices [e.g. timing, staffing difficulties, etc.]. We want you to know that we are committed to addressing all of those concerns and questions before making any changes to the current requirements for the issuance of these notices."

Because the Medicare notice "is a regulation on the books," Warren points out, "HCFA has its neck stuck out. If they don’t do something to enforce it, and if someone brings suit because a patient is discharged too soon, it’s a no-win situation."