Know the new HINNs; use QIO as a resource

Patients more informed about right to appeal

Changes to Medicare’s Important Message (IM), informing patients of their rights to Medicare services and to question discharge decisions, which went into effect in July 2007, coincided with a revamping of the hospital-issued notices of noncoverage (HINNs) that notify patients of their financial responsibility if they receive services not covered by Medicare.

The Centers for Medicare & Medicaid Services (CMS) has published notices of non-coverage, including those issued prior to hospitalization (Advanced Beneficiary Notice and Preadmission/Admission) and those issued after admission — HINNs. These notices are to be provided to Medicare beneficiaries prior to admission, at admission, or at any point during an inpatient stay if the hospital determines that the care the beneficiary is receiving, or is about to receive, might not be covered because it is either:

  • not medically necessary;
  • not delivered in the most appropriate setting; or
  • custodial in nature.

The coincidence of the new version of the IM and the new set of HINNs, each of which requires additional discharge planning, documentation, and review, has led to some confusion among discharge planners. The confusion centers mostly around who should get a HINN, and when, say experts.

“I’m at conferences and regularly encounter people who are wondering what forms to give and what order to give them in,” says Toni Cesta, PhD, RN, FAAN, vice president, patient flow optimization at North Shore-Long Island Jewish Health System in Great Neck, NY. “The change only just went into effect, and people are misinterpreting it already.”

The importance to both patients and hospitals is evident: Patients have the right to appeal their discharge and be informed that they may be incurring expenses for noncovered services; hospitals must be diligent in documenting discharge plans and requests for review so that they can be paid for medical services, either by Medicare or other payers, or the patient. The financial concerns of the hospital and the patient add weight to the need to comply with CMS regulations on delivery of the IM and HINNs.

When does the HINN come in?

If a Medicare beneficiary does not agree with the physician’s decision to discharge the patient or transfer him or her to a lower level of care, the beneficiary can request a review by the hospital’s Quality Improvement Organization (QIO). Having already received the IM upon admission, and again within 48 hours of discharge if the hospital stay exceeds 48 hours, the patient then receives a “Detailed Notice.” This written notice explains, in language patients can understand, the reason the physician has determined that the patient no longer necessitates an acute level of care with an explanation of the reasons that the patient no longer meets Medicare criteria.

This same Detailed Notice is the one the hospital sends to the QIO for a review of the discharge decision. Once a decision is made by the QIO on the appropriateness of the discharge, a decision must be made by the hospital about whether to give the patient a HINN advising of the potential that he or she might be liable for non-covered hospital services. This decision is made by the hospital utilization review committee after reviewing all the facts of the individual patient’s situation.

At Forsyth Medical Center and Medical Park Hospital in Winston-Salem, NC, case management director Crystal J. Redding, RN, MHA, says a multidisciplinary team conducted a study before the new IM was enacted, to draw up a “discharge notice action plan.”

“Then we got in touch with our QIO,” Redding says. “You need to be in sync with CMS, but you also need to be in sync with your QIO. And your QIO is a great resource for hospitals as we work through this process.”

While many in discharge planning predicted that the change in the patient notification and appeals process would lead to a greater number of appeals and longer hospital stays, Redding says that’s not been the case at her hospital.

“We have seen the number of HINN letters decrease,” she says. “And we have had multiple patient appeals, but [the discharge decisions] have all been upheld in the hospital’s favor.”

Even with careful planning and preparation, unique cases will still emerge as the full measure of the new appeals process unfolds.

“There are unique situations that don’t always fit into a protocol and as soon as one situation is solved, a new one will show up,” says Jackie Birmingham, RN, MS, CMAC, vice president of professional services for Curaspan Inc., a Newton, MA, health care technology firm. “If you have an uninsured, homeless, undocumented person, do you give him or her a HINN? The answer is: It depends on the patient’s situation and the advice of the hospital utilization review committee with input of the QIO.”

The best thing those involved in discharge planning can do to prepare is to learn as much as they can about the appeals process, Redding advises, and in particular to become familiar with how their QIOs handle reviews and if there is any regionally specific information that applies. (To find your state’s QIO, go to; under “About Us” in left navigation bar, click on “QIO Listings.”)

Alice Vallar, senior director for federal health care assessment for IPRO, the QIO for New York, says that the increase in volume of calls her office has received since the change in the IM has come from beneficiaries, their representatives, and hospitals.

“IPRO provided to the hospital community statewide Webex presentations prior to the implementation of the [IM] program, which outlined both the hospital’s responsibility and the QIO role in the appeal process,” says Vallar. (IPRO’s PowerPoint presentation on the appeals process is available on-line at

Donna McIvor, RN, BSN, appeals manager for California QIO Lumetra, says the training she did for hospitals prior to the IM change has proved “priceless.”

“Every time I did a training, my phone calls would drop off to almost nothing for a couple of weeks afterward,” she says. “The education to hospitals helps a lot, and I tell the hospitals that we are working together — we are here because the beneficiary needs us, and they are there because the beneficiary needs them.”

The biggest share of the education McIvor provides to hospital staff centers around valid delivery of the IM — making sure the right patients get the IM in the right way, with enough time to digest it and make a conscious decision about an appeal.

“CMS doesn’t want to give [beneficiaries] the notice on the day of discharge,” she explains. “They want them to have it 48 hours in advance, to think about it, to talk to family members, and to decide.”

McIvor says calls to her office have quadrupled since the change in the IM process — she has had to hire another employee to help handle the volume.

With the increase in calls has come a slight increase in overturned discharge notices, she reports.

“We have a 35% rate of overturn of hospital appeals for our managed care Medicare patients with HMOs vs. a 30% overturn rate for regular, fee-for-service Medicare patients,” says McIvor. She attributes the higher rate of overturn for HMO patients to it being in the HMOs’ best interest “to deliver care, but not deliver an exorbitant amount of care,” and thus to discharge patients sooner than some patients might like.

Know your HINNs

The HINNs now most likely to be used in discharge planning include:

• The Preadmission/Admission HINN is used prior to an entirely noncovered stay, and replaces HINNs 1 and 9. The hospital should use this HINN to notify the patient that Medicare is not likely to pay for his or her admission because it’s not considered to be medically necessary or it could be furnished safely in another setting.

• The Notice of Hospital-Requested Review (HRR), formerly known as HINN 10, is used when a hospital requests a QIO review of a discharge decision when the attending physician does not concur with the hospital’s opinion about the readiness for discharge. This HINN notifies patients that the hospital has requested a medical opinion from the QIO because it 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 reviewing the facts and may be contacting the patient to discuss the case.

• HINN 11 (Noncovered Services During a Covered Stay) is used to notify patients that their physician has ordered specific services that are potentially not covered during a hospital stay even if the hospital stay is covered. Hospitals 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 related to the reason for admission, 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.

• HINN 12 (Noncovered Continued Stay Notice) is one of the revised notices. This HINN notifies patients that the hospital believes Medicare may not pay for their continued hospital stay beginning on a certain date. The notice includes the estimated cost of the patient’s stay, beginning from the date of noncoverage.

The discharge process, based on the Social Security Act § 1861(ee), enacted in 1988 with only minor changes in the standards, was intense prior to July 2007.

Now, to be an effective discharge planner, you must have knowledge and experience of not only the discharge process, but a knowledge base on the financial needs of patients and the hospital. Patients are entitled to appropriate and quality care, and hospitals are entitled to be paid to deliver that care. Discharge planners are expected to be advocates for both, Birmingham points out. This can be accomplished when the intent of the services is known, and the needs of the patients come first.

In particular, physicians focus on medical necessity; discharge planners should focus on working with the physician and the patient to show that the necessary care can be safely delivered in another setting.

“That’s the job of discharge planning, and doing it effectively will assure that the patient is in the right place at the right time for the right services, and the financial issues shouldn’t even be an issue,” Birmingham says.


For more information, contact:

  • Jackie Birmingham, RN, MS, CMAC, Vice President, Professional Services, Curaspan Inc., Newton, MA. E-mail:
  • Toni Cesta, PhD, RN, FAAN, Vice President, Patient Flow Optimization, North Shore-Long Island Jewish Health System, Great Neck, NY. E-mail:
  • Donna McIvor, RN, BSN, Appeals Manager, Lumetra. One Sansome Street, San Francisco, CA 94104. Phone: (415) 677-2166.
  • Crystal J. Redding, RN, MHA, Director of Case Management, Forsyth Medical Center, Medical Park Hospital, Winston Salem, NC. E-mail:
  • To download HINNs and their instructions, go to the CMS web site,