IMs gain importance as CMS focuses on discharge planning
Use documents as proof you talked to patients
If you aren't issuing the Important Message from Medicare (IM) as required by the Centers for Medicare & Medicaid Services (CMS), your hospital could face serious repercussions when surveyors review your hospital's compliance with the Medicare Conditions of Participation.
"The rule for issuing IMs is six years old, but it's more important than ever for case managers to make sure their hospitals are in compliance. CMS is paying close attention to patient rights and safety in the discharge process and looking for more evidence that hospitals are talking to patients about discharge planning," says Jackie Birmingham, RN, MSN, MS, vice president emerita, Clinical Leadership at Curaspan Health Group, Newton, MA.
The revised interpretive guidelines for the Medicare Conditions of Participation include a provision for surveyors to review current and closed charts for evidence that discharge planning was discussed in a timely manner, Birmingham points out.
If hospitals fail to issue the mandated IMs as required, they could be fined or, since IMs are part of the Medicare Conditions of Participation, could lose their ability to receive reimbursement from Medicare, points out Linda Sallee, MS, RN, CMAC, ACM, IQCI, director for Huron Healthcare with headquarters in Chicago.
CMS requires hospitals to give all inpatient Medicare beneficiaries the IM, which informs them of their right to request a review of a discharge decision, as close as possible to admission but no later than two days after admission. IMs can be delivered at preadmission as long as it is no more than seven calendar days before the admission. If patients remain in the hospital for two additional days, they must receive a second copy of the notice, frequently referred to as a "follow-up copy." Both notices must be signed by the beneficiary or his or her representative. Case managers should give patients copies of the IMs and place copies in their charts.
The rule applies to traditional Medicare beneficiaries, beneficiaries enrolled in Medicare Advantage programs, patients who are dual eligible when Medicare is a secondary payer, and other Medicare health plans that are subject to Medicare regulations.
IMs should be given only to patients who have been admitted for an inpatient stay, says Deborah Hale, CCS, CCDS, president and chief executive officer of Administrative Consultant Service, a healthcare consulting firm based in Shawnee, OK. "I find that some hospitals are giving the IM to patients in observation and this is not appropriate," she says.
Instead, give outpatients, including patients receiving observation services, an Advance Beneficiary Notice of Non-Coverage (ABN) if Medicare is not likely to pay for services because they aren't covered or are not medically necessary. The ABN notifies the patients that they will be liable for the cost of services if they receive them, Hale says. For instance, it would be appropriate for patients receiving observation services who are resisting going home, she adds.
Hospitals haven't been audited simply for compliance with IM regulations to this point, Sallee says. But surveyors who are reviewing hospitals for adherence to the Medicare Conditions of Participation may uncover problems with the delivery of the IMs or Hospital-Issued Notices of Noncoverage (HINNs), or state Quality Improvement Organizations or other auditors may determine that IMs and HINNs are not being issued as required in the course of auditing for other issues, she adds.
Karen Ford, MSN, RN, director of case management for Scottsdale (AZ) Healthcare system, points out that not everybody who interacts with patients has the expertise needed to deliver the IM and explain what it means, and recommends using case managers to deliver the IMs. "Case managers have the best understanding of CMS rules and education and have the expertise to answer questions. Some Medicare patients get confused and don't understand why they are being asked to sign the IM. That's why communication is so important," Ford says.
Case managers should go beyond just handing patients a follow-up copy of the IM letter and checking off a box, Birmingham says. "Case managers should explain in detail what the IM means and use the IM as a tool to form a relationship with patients and let them know that the hospital staff really cares about what happens to them after they leave the hospital," she says.
In addition to being a good communication tool that case managers can use to start preparing patients for their discharge, the IM can provide documented evidence that case managers talked to the patient and/or his or her family member or caregiver about discharge options and their right to participate in their discharge plan, Birmingham says.
When a patient wants to appeal his or her discharge, case managers should point out the telephone number for the QIO on the IM but are not required to make the telephone call, Sallee says. Patients must appeal by midnight on the date the discharge order is issued in order for the appeal to be timely. If the QIO agrees with the hospital, the patient becomes responsible for the cost of the continuing stay at noon of the day following the notification of the determination. "If patients don't make the midnight deadline for an appeal, they are responsible for the bill, but they may get a refund if the QIO agrees with them," Sallee says. If patients receive the IM on the day of discharge, Medicare requires hospitals to allow patients to stay up to four hours after the IM is issued to give them a chance to appeal.
When patients appeal their discharges, case managers should deliver a Detailed Notice of Discharge to the patient or his or her representative as soon as possible after learning of the appeal to the QIO. The notice should explain in detail why the patient no longer meets criteria for a continued stay and why services no longer will be covered. It should include the estimate of the cost per day the patient will be responsible for if he or she chooses to stay when the QIO rules in favor of the hospital. Instances where the QIO disagrees with the hospital about a discharge rarely occur, Sallee adds.
Use the IM as a tool to track the times that patients appeal and how the QIO rules. Then conduct case studies to determine what happened to prompt the appeal, Birmingham suggests.
When patients appeal a discharge, it gives case managers a chance to review the discharge planning process, Birmingham says.
Drill down to determine why the patient felt the need to appeal and look for ways that the process could have been improved to avoid the appeal, she adds. Look at how long patients were in the hospital, how sick they were, whether they were screened for complex discharge needs, what the discharge plan was, and whether there were issues like resistance from the family or that the only post-discharge facility with appropriate available beds was too far from the patient's home. Track what your utilization review committee did to work through this particular issue. "Case managers need to use their internal resources, namely the utilization review committee, to come up with a process that can deal with this infrequent but anxiety-producing situation," Birmingham says.
Analyzing your appeals is a great opportunity to understand why people want to stay since most patients want to get out of the hospital as quickly as possible, Birmingham adds.
• Jackie Birmingham, RN, MSN, MS, Vice President emeritus, Clinical Leadership at Curaspan Health Group, Newton, MA.
• Deborah Hale, CCS, CCDS, president and chief executive officer of Administrative Consultant Service, Shawnee, OK. email: firstname.lastname@example.org.
• Linda Sallee, MS, RN, CMAC, ACM, IQCI, Director, Huron Healthcare, Chicago. email: email@example.com