Know your HINNs and when to deliver them

And when to use Condition Code 44

When hospitals determine that the care patients are receiving or are about to receive will not be covered by Medicare because it is not medically necessary, not delivered in an appropriate setting, or is custodial in nature, the hospital should provide the patient with a Hospital-Issued Notice of Noncoverage (HINN) to inform them that they will be responsible for the bill if they choose to stay in the hospital.

CMS requires hospitals to provide HINNs to patients before admission, at admission, or at any time during an inpatient stay if the hospital determines that the care the patient is receiving or is about to receive is not covered because it is not medically necessary, not delivered in an appropriate setting, or is custodial in nature.

If hospitals don't give patients a HINN when inpatient services aren't covered by Medicare, the hospital cannot bill the patient for the services later on, according to Deborah Hale, CCS, CCDS, president and chief executive officer of Administrative Consultant Service, a healthcare consulting firm based in Shawnee, OK. "If a HINN isn't issued, the hospital would be unable to collect payment from the patient for services rendered. CMS also provides hospitals with the option of using Condition Code 44 for correcting an unnecessary admission, but the physician responsible for the care of the patient must agree that the inpatient admission was unnecessary and the patient must be notified in writing before discharge," she says. When Condition Code 44 is used to change the patient's status from inpatient to outpatient, the hospital can collect payment from Medicare for Part B services, she adds.

Before Medicare began requiring hospitals to give patients the Important Message from Medicare (IM), notifying them of their right to appeal their discharge, there were 12 HINNs. The IM requirement eliminated HINNs 2 through 9, says Linda Sallee, MS, RN, CMAC, ACM, IQCI, director, for Huron Healthcare with headquarters in Chicago.

"CMS has very specific requirements about when each of the HINNs should be delivered and what the HINN letter should say. All of the HINNs must be signed by patients and a copy placed in their file," Sallee adds. If someone refuses to sign a HINN, a copy should be placed in their files and a notation made of their refusal.

Here's a look at the HINNs and when to use them:

The Preadmission/Admission HINN, also known as HINN 1, notifies patients that Medicare is not likely to pay for the admission because it is not likely to be considered medically necessary or can safely occur in another setting. The preadmission/admission HINN should be delivered when a physician wants to admit a patient who will not meet admission criteria or has already admitted a patient and the hospital determines that he or she never met admission criteria, Sallee says. Examples include social admissions when patients don't meet criteria but the physician doesn't want them to be at home, or patients who are admitted for procedures that should be outpatient procedures.

If the Preadmission/Admission HINN is delivered before 3 p.m., the patient becomes liable for charges on that day. If it's delivered after 3 p.m., the patient becomes liable the following day, Sallee says. The HINN should inform patients that they may ask the Quality Improvement Organization (QIO) to review the HINN 1. Case managers must get patients to sign the HINN, indicating that they received it, and put a copy in their files.

HINN 10 or the Notice of Hospital Requested Review (HRR) should be given to patients when the hospital has determined that the patient no longer meets inpatient criteria for a continued stay and the attending physician disagrees, says Jackie Birmingham, RN, MSN, MS, vice president emerita, Clinical Leadership at Curaspan Health Group, Newton, MA. The notice informs the patient that the hospital is asking the QIO to review the case and that the QIO may be contacting the patient for more information.

Before the HRR is issued, the hospital should go through the utilization review process, have the physician advisor contact the attending physician, and if there still is disagreement about the discharge, have the utilization review committee review the case and attempt to come to an agreement with the attending physician, Birmingham says. The hospital's utilization review committee, which must be chaired by a physician, must agree to request a QIO review of a continued stay, she points out.

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

HINN 11 (Non-Covered Services During a Covered Stay) notifies patients that their physician has ordered specific services, such as therapeutic or diagnostic services, that may not be covered because they are not medically necessary based on the reason for admission, but the patient still meets inpatient criteria for a continued stay. For instance, if the physician wants the patient to have a non-covered experimental drug, or a cosmetic procedure during a medically necessary stay, the HINN 11 notifies the patient that if they have it, they will be responsible for the cost, Sallee says.

The hospital must give a copy of the HINN 11 to the patient as well as to the attending physician. The HINN 11 also should include the actual total of the patient's financial responsibility if the services are received, Birmingham says.

HINN 12 (Non-Covered Continued Stay) notifies patients that the hospital believes Medicare may not pay for their continued stay beginning on a certain date. It should include, in plain language, the reason the stay will not be covered and the estimated cost of the stay for which they are potentially liable, Sallee says. This HINN should be issued in conjunction with the hospital appeal notices, she says.

The HINNs are only one of the ways hospitals can deal with an unnecessary admission or a continued hospital stay, Hale points out.

"I don't see many hospitals routinely issuing the HINN, as they prefer to address patients' healthcare through diplomacy and collaboration. For these hospitals, the HINN is the last resort and doesn't become necessary unless the case manager and physician are unable to gain the cooperation of the patient and family for services to be provided in a more appropriate setting than an acute care hospital," Hale says.

For information on the HINNs and to download the HINN requirements and letters for each, visit: