Here’s what you need to know about Medicare’s Important Message

Know function of IM, who should get it, and that it’s understood

Medicare’s Important Message (IM) has been around for years, but a change to the rule and the process for imparting the IM has thrown many in discharge planning for a loop.

But it’s a change that’s good for patients, according to Mirean Coleman, LICSW, senior policy associate for the National Association of Social Workers. “It involves the patient in the discharge plan, and that’s very important,” Coleman says. “Now the patient knows they have a say in what will happen in their discharge.”

Prior to July 2, 2007, when the Centers for Medicare & Medicaid Services (CMS) implemented the revision of the Notification of Discharge Rights, the Important Message from Medicare was delivered to patients upon admission to the hospital. That IM describes Medicare beneficiaries’ rights to receive necessary care. The original did not include wording to indicate that the patient had a right to appeal decisions about continued stay. In the revised version, Medicare has required that patients receive the revised IM that includes language about how to appeal, or request a review, of the decision to be discharged. Not only was that new wording added, but the rule required that the revised IM be given to a patient within 48 hours of discharge. If the first IM was given more than 48 hours before discharge (short-stay patients may need only one copy), then a second copy would be required.

“We went from a procedure that was a routine part of admission that basically involved our admitting registration staff to a procedure that involves multiple disciplines throughout the hospital,” says Crystal J. Redding, RN, MHA, director of case management for Novant Health/Triad Region at Forsyth Medical Center and Medical Park Hospital in Winston-Salem, NC.

She adds, only half-joking, "So with every patient, you now have two mandated opportunities to educate them of their rights to appeal their doctor’s discharge decision."

A new spin on an existing idea

What once was broadly viewed as a simple notification upon admission has become a source of confusion as staff responsible for discharge planning struggle to make sure they understand what the changes are and what is required. If you’re one of those people, you’re certainly not alone.

CMS has for several years required acute care facilities to give all Medicare beneficiaries who were going to be admitted as inpatients a copy of the Important Message from Medicare, a document that spells out the patient’s rights to benefits. In 2006, CMS published its final rule revising the IM process, requiring hospitals to deliver a revised version of the IM upon admission, and, if the patient’s stay was longer than two days, to deliver another copy for the patient to review and sign within 48 hours before he or she was dismissed. (Click here for comparison of new and old versions of the IM.)

No change in rights, just notification

The change to the IM process doesn’t change patients’ rights — they’ve always been entitled to appeals and to participate in their discharge planning. But the new process has created confusion among patients as well as hospital staff, according to Jackie Birmingham, RN, MS, CMAC, vice president of professional services for Curaspan Inc., a Newton, MA, health care technology firm.

“Before July 2, the only patients who were informed of their right to appeal were the patients who received a HINN [hospital-issued notice of noncoverage],” she points out. A HINN is used to inform patients of their financial liability. HINN is a general term used to indicate one of the five or so types of financial notices. “Now all patients are informed, upon admission, of their rights to acute care services, to participate in discharge planning, and to appeal a discharge if they believe they’re being discharged too soon.” (Editor’s note: In addition to making changes in the delivery of the IM from Medicare, CMS has revamped its set of HINNs, which inform patients of any potential financial liability if they receive services that Medicare does not cover. Click here for more on changes involving HINNs.)

“Patients always had this right, but it was not put in front of them as it is now,” explains Redding. “And the biggest confusion is that they don’t truly understand what their rights are. When we present them with the second copy [of the IM], we ask if they have questions and do they understand, and they almost always say they understand, but they really don’t.”

When patients are admitted, the original copy of the notice should go into the medical record. When the decision is made to discharge a patient, the patient should receive a copy, either of the original or a second printed copy, of the IM to remind him or her of the right to appeal discharge. Ensuring that the notification occurs in a timely manner and the patient is afforded the opportunity to ask questions requires a coordinated effort among everyone involved in planning for discharge — social workers, case managers, physicians, and nursing staff.

Medicare’s intent with the IM is to make sure patients understand the discharge process and their rights under it, and repeating the notification helps ensure that. Patients who are very ill or under stress at the time of admission may not take in everything they sign or have explained to them.

But merely having the patient sign the form before discharge does not meet the intent of the IM, Redding says.

“We want to make sure the patient understands what their rights are. We created a dedicated line in the hospital, with the number printed on the form and given to all patients, for them to call with questions,” Redding explains. While patients might indicate — and believe — they understand their rights at the time they are given the IM, experience has shown that when the utilization review nurse walks out of the room, questions start coming to mind.

“The patient can call that number, and someone from utilization review will come back to their room and answer their questions. Or, they can ask us to come talk to a family member.”

The revised IM process is based on a rule that grew out of a lawsuit filed against Medicare. The lawsuit, Weichardt v. Leavitt, defines the intent of the settlement for notification of patients’ rights. However, when the overhaul of the IM was in process, there were also some changes to the Social Security Act § 1879 that address the notification of Limitations of Liability (LOL). This concurrent revision created some confusion and resulted in the process of each becoming more difficult to understand.

There is a lot of information out there about the IM and a lot about the notices of financial liability, but Birmingham explains that there is no hard and fast guidance on the blending of the intent when these two rules overlap. Even experts familiar with the IM can’t answer all the questions without a great deal of time and effort. (Editor’s note: Reference on the Social Security Act § 1879 Limitations of Liability rule can be found in the sources/resources below.)

“It’s a little like when the ADA [Americans with Disabilities Act] came out. The rule said, ‘Make your facility accessible,’ but it didn’t say what ‘accessible’ means, or how to build a ramp,” says Birmingham.

“With the Important Message, there is no right or wrong way of implementing it — it’s the intent of the rule and the application that you have to work out,” she says. “With the ADA, what happened was, as each challenge went to court, a judge would decide what was needed on a case-by-case basis. [Implementing the IM] is also almost on a case-by-case basis.” Because of the overlap of the IM and the financial liability notices, the hospital is not only dealing with its own utilization review committee, but also with its assigned Quality Improvement Organization (QIO).

To appeal or not to appeal

In the accompanying flow chart is an example of one possible scenario in which a patient “appeals” or “does not appeal.” You’ll see that the decision to issue a HINN is one that is made based on the circumstances for a specific situation.

As each hospital gains experience with its QIO, questions arise based on the unique set of circumstances for an individual patient’s situation. The sorting out of actions to be taken by the hospital is a time-consuming process, but an important one to ensure that patients are informed of rights and of financial liability. There are at least five financial liability notices and a lot of variations in patients’ stories. The best thing hospitals can do is to track the specifics and the replies from their QIOs to make sure they are building a set of protocols on what to do when the next similar situation arises, Birmingham says.

Compliance a major undertaking

Redding says when Forsyth Medical Center mounted a risk assessment leading up to the July 2 implementation of the IM change, the question that was on her colleagues’ minds was: “Everybody wants to do it right, and tries hard to do it right but what is right?”

“We did a risk assessment at our hospital, and it told us that this was major,” Redding says. The sheer number of patients affected — not only Medicare primary patients, but also managed care Medicare patients, and patients for whom Medicare is their secondary payer after their primary insurance — told Redding that the staffing demands would be major, as well.

“We had to make sure, first of all, that we were capturing all the appropriate people,” she explains. “We read the guidance from CMS, and tried to identify in the prior six months how many people who were inpatients in our facility would be affected, and we came up with this astronomical number.”

Once Forsyth Medical Center identified a rough scope of the change, a team of hospital staff from multiple departments came together to develop a plan:

• Due diligence. “We did our best to gain a complete understanding of the CMS regulation and its implications,” Redding recalls. “We reviewed the rule, assessed the implications of noncompliance, assessed the resources we had, and what we needed staffing-wise to achieve compliance.”

• Planning and pre-implementation. Redding’s hospital was able to get additional clerical assistance to help take care of the “mass quantities” of paperwork that the change entailed. “On any day, we have 250 patients who have Medicare in some form or fashion. We worked with our [information technology] department to develop work lists and reports that identified patients with Medicare plans, and developed a report to tell us whether the Important Message was signed during admission,” she continues. “Then, for the clerical staff we hired, one of their jobs was to get it signed in the first 48 hours [after admission].” Also, they developed a method to make sure that patients who came in first as outpatients on observation but then converted to inpatient status without going through admissions were not missed.

• Work out the bugs. During the first two weeks that the plan was operational, Forsyth Medical Center’s most seasoned case managers worked through it, “to see what the bugs were,” Redding recalls. “We knew there would be lots of things that didn’t work quite right, so those employees helped tweak the process and make sure we had a good patient flow.”

• Formal policies and training. Once formal policies were written up and distributed, team meetings were convened — first three times a day, and now twice a day. Utilization review is staffed seven days a week, and education of everyone involved in admissions and discharge planning continues.

Fear of longer stays unfounded

“Before, patients didn’t realize that they have a say in their discharge, and they’ve just done as they’re told,” Coleman says. “Now they know that if something is not functional to them, they have the right to work it out with hospital staff and appeal to Medicare for assistance if it’s not worked out to their satisfaction.”

But Redding and other discharge planners say they have found that one of the feared consequences of the change to the IM process has not materialized. Because of the addition of a second notice within 48 hours of discharge, some experts projected that hospital stays would be extended.

“The impact on our staff has been tremendous, in terms of the amount of paperwork and the whole process itself,” Redding says. “But I can’t say it’s really significantly affected the length of stay. I think we have been able to manage it as well as we could have.”

Case managers say CMS’ ultimate goal — to better inform patients of their rights — shouldn’t necessarily cause patients to appeal discharges more often.

“Part of our scripting [at admission] is telling the patient to be sure to call us with any questions and we’ll talk with you, and to let them know that prior to being discharged that they will see us again, and that we’ll be bringing a copy of this IM back and reviewing it with them a second time,” says Redding. The dedicated phone line Novant Health established for patients’ questions provides an ongoing log of the kinds of questions patients are asking about their rights regarding discharge and appeals.

“We log what the question is, who called, and what the issue is, and that has allowed us to improve our scripting,” she says. “It all boils down to good communication with the family and patient.”

Coleman says that while the changes to IM notification mean “a little additional work” for social workers and case managers, “I have heard very positive responses from patients who are happy to hear this and know someone is on their side to make their discharge a positive experience.

“I think what is happening is a good thing, from a patient experience perspective, and it makes clinical social workers and other staff more accountable for their actions in discharge planning,” she adds.


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