General Guidelines and Cautions
The following information for Medicare beneficiaries and their advocates is useful in challenging a discharge or reduction in services in hospital, skilled nursing, home health, and hospice care settings:
Question treating physicians, nurses, social workers, home health care providers, and other care providers about necessary services as the beneficiary’s condition either improves, remains the same, or requires more services. If the beneficiary has opinions and concerns about care, voice them and participate fully in all care decisions.
Become familiar with Medicare guidelines about eligibility for hospital and home and community based care, including nursing facility services and home health services available under the Medicare and Medicaid programs. It is also important to explore other options for services that may be available through other state-based sources of coverage for home and community-based services (HCBS).
Identify and become familiar with available health care services such as visiting nursing services, home health agencies, nursing homes, respite care, friendly visiting services, and religious and civic groups that provide services. An important source of information about services is the Elder Care Locator 1-800-677-1116. In addition, contact the Medicare program’s information line B 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048 for the hearing impaired).
with discharge planning and its interplay with "transitions," an
activity that includes the preparing for and moving from one
care setting to another. See "Breathing
Life Into Discharge Planning" by Alfred J. Chiplin, Jr.
Use physicians and suppliers who are Medicare-participating providers and, as such, have agreed to accept the Medicare reasonable charge amount, less the 20% beneficiary co-payment, as payment in full for Medicare-covered physician and supplier services (See, 42 U.S.C §§1395u(b)(3);1395n; 42 C.F.R.§§ 410.152(amounts of payment); 424.55(b)(payment to suppliers); 414.48 (limiting charge for non-participating suppliers); see also, 400.402(definitions specific to Medicare, including payment on an assignment related basis) .
Beware of using physicians who have opted out of Medicare and the impact of using such physicians and consequent impact on access to Medicare coverage for the services. See, 42 C.F.R. §§405.400 et seq.
Pay attention to access to coverage concerns that may arise from recently instituted Medicare rules that exclude and limit payment for hospital acquired conditions (HACs) and things that should never happen in hospitals (never events).
Contact your local Medicare office or the Social Security office for a list of Medicare participating providers and suppliers in your area.
Obtaining Necessary Assistance
If a beneficiary needs help in filing a complaint with the QIO, contact the Elder Care Locator for information about community-based Medicare assistance, including legal assistance providers funded under the Older Americans Act, the Legal Services Corporation, or private attorney services, or through your network of Health Insurance Counseling Program (HICAP)[sometimes called State Health Insurance Counseling Programs (SHIPs) or Insurance Counseling Assistance (ICAs).]. (Use the eldercare locator number listed above for information about the location of HICAPs/SHIPs/ICAs in your area.). Moreover, QIOs have an obligation to assist Medicare beneficiaries in completing and filing a written complaint.
Before leaving the hospital, make sure that the hospital has discussed post-hospital care needs and that a post-hospital plan of care and services has been developed prior to discharge.
Make sure that
one’s discharge plan identifies necessary services, including
how those services will be provided, and requesting assistance
in putting services in place.
Hospital Discharge Planning Services
Conducting, on a timely basis, a discharge planning evaluation for all patients identified by their physicians as needing discharge planning services as well as any patient requesting a discharge planning evaluation.
Placing the discharge planning evaluation in the patient’s medical record for use in planning post-hospital services.
Discussing with the
patient (and representatives) the elements of the discharge plan
Arranging, when requested by a patient’s physician, for the development and the initial implementation of a discharge plan for the patient.
Assuring that discharge planning evaluations and discharge plans are developed by, or under the supervision of, a registered professional nurse, social worker, or other appropriately qualified personnel. (42 U.S.C. §1395x(ee); 42 C.F.R. §482.43. Condition of participation: Discharge planning).
When a Quality Improvement (QIO) or hospital makes a determination whether an inpatient hospital stay is medically necessary, it must make an individualized assessment of the patient’s need for skilled nursing facility care. If the patient requires skilled nursing facility care, the QIO or hospital must determine whether there is a bed available to the patient in a participating skilled nursing facility in the community or local geographic area (42 C.F.R. §§424.13(b)(1), 412.42(c)(1)).
Discharge from the Hospital Setting
A follow-up copy of the signed IM is given again as far as possible in advance of discharge, but no more than 2 calendar days prior to discharge. 42 CFR §405.1205(c)(1); 42 CFR §422.620(c)(1). Follow-up notice is not required if the provision of the admission IM falls within 2 calendar days of discharge. 42 CFR 405.1205(c)(2)(Traditional Medicare) and 42 CFR 422.620(c)(2) (Medicare Advantage). The exception to the two-notice requirement is an individual who is in the hospital for just 3 days. One IM can be given on day 2, and suffice as both the initial and discharge IM.
The patient becomes financially responsible for the services provided beyond the second day following the date of the notice. 42 C.F.,R. §412.42(c)(3)(ii). See also 42 C.F.R. §§422.620, 489.27 (Beneficiary Notice of Discharge Rights – Medicare Advantage (MA) plans).
For a hospital stay, a beneficiary must request expedited review, orally or in writing, by noon of the first working day after he or she receives written notice that the hospital has determined that the hospital stay is no longer necessary. 42 CFR §405.1206(d)(1); 42 CFR §422.622(d)(1).
The beneficiary (or his or her authorized representative), when requested by the QIO, must be prepared to discuss the case with the QIO. 42 CFR §405.1206(d)(2); 42 CFR §422.622(d).
On the date that the QIO receives the beneficiary’s request, the QIO must notify the hospital that the beneficiary has filed a request for expedited review. 42 CFR §405.1206(e)(1)); 42 CFR §422.622(e)(1).
The hospital must supply any information, including medical records, that the QIO requires to conduct its review and must make it available, by phone or in writing, by the close of business of the first full working day after the day the beneficiary receives notice of the planned discharge. 42 CFR §405.1206(e)(2); 42 CFR §422.622(e)(2).
When the beneficiary requests an expedited determination in accordance with §405.1206(d)(1), the QIO must make a determination and notify the beneficiary, the hospital, and physician of its determination by close of business of the first working day after it receives all requested pertinent information. 42 CFR §405.1206(e)(5); 42 CFR§422.622(e)(5).
If the QIO sustains the decision to terminate services or discharge the beneficiary, the beneficiary may request expedited reconsideration, orally or in writing, by noon of the calendar day following initial notification. The reconsideration will be conducted by the QIC, which must issue a decision within 72 hours of the request. If the QIC does not comply with the time frame, the beneficiary may escalate the case to the administrative law judge level. See 42 CFR 405.1204.
Beneficiaries retain the right to utilize the standard appeals (42 U.S.C §1320c-3(a)(14); 42 C.F.R. 466.70 et seq.) process rather than the expedited process in all situations. A QIO may review an appeal from a beneficiary’s request that is not timely filed, but the QIO does not have to adhere to the time frame for issuing a decision, and the limitation on liability does not apply.
It is the hospital and not the health plan that provides the notice for beneficiaries in hospitals that are part of a Medicare Advantage (MA) Organization. 42 C.F.R. §422.620(c).
A person in a Medicare Advantage Organization hospital who misses the PRO appeal deadlines can use the Medicare Advantage expedited appeals process. 42 C.F.R. §422.584.
Discharge Decision Concerns
Notification of the beneficiary’s discharge and appeal rights should not be hindered when the hospital cannot anticipate the date of discharge. According to CMS, if hospitals cannot anticipate the discharge date, the follow-up IM notice may be given on the day of discharge, at least four hours in advance of the actual discharge.
Beyond requiring that the follow-up IM be given at a minimum of four hours in advance of discharge, CMS does not require the hospital to again obtain the patient’s signature when this follow-up IM is given. The hospital may simply distribute a copy of the signed and dated IM that was given at admission. However, hospitals are not precluded from obtaining a new IM and verifying signature from the beneficiary. By allowing this practice, CMS has made it possible for hospitals to eliminate the need for a follow-up copy of the IM during inpatient stays of up to 5 days. This lack of timely notice may hinder the ability of Medicare patients to be fully aware of and exercise their appeal rights.
Appeals of Hospital Discharge
When a hospital (with physician concurrence) determines that inpatient care is no longer necessary, the Medicare beneficiary has the right to request an expedited QIO review. The CMS guidelines provide that the appeal for expedited review must be made before the beneficiary leaves the hospital.
In order for the review request to be considered "timely," beneficiaries must submit their requests in writing or by telephone no later than midnight of the day of discharge and before they leave the hospital. The beneficiary, therefore, should not be discharged upon requesting the QIO review, so long as the request is made on the same day.
The beneficiary or qualified representative should be contacted by the QIO to discuss the case with the QIO and provide any necessary information that may be required. The hospital is required to submit all pertinent information to the QIO. The patient or his or her representative also has the ability to obtain the same information from the hospital and/or QIO. In addition, the QIO should obtain medical records from the hospital, including speaking to the patient’s physician(s). A timely request will trigger the QIO to render a decision within 1 calendar day after receiving all of the necessary information.
The Detailed Notice of discharge must be delivered "as soon as possible" after the beneficiary has requested a QIO review, but no later than noon of the day after the QIO notifies the hospital of the beneficiary’s request for the review. Under the CMS guidelines, hospitals are only required to deliver the Detailed Notice after the beneficiary has contacted the QIO for expedited review or when the beneficiary requests more detailed information from the medical care provider prior to requesting a QIO review. The Detailed Notice is not an official Medicare decision. It is designed to give the patient further explanation about why the hospital and/or physician believe that the medical services are no longer necessary.
Beneficiaries are not financially liable for hospital costs incurred during a timely QIO review; they are responsible only for coinsurance and deductibles. Further, the burden of proof lies with the hospital to demonstrate that the discharge is the correct decision based on either medical necessity or other Medicare coverage policies. If the QIO decision is in agreement with the hospital (unfavorable to the patient), the beneficiary becomes liable for the medical expenses beginning at noon on the day after notification of the decision is given.
Information on the Required Notices
What Information Must the Important Message from Medicare ("IM") Contain?
The name(s) of the patient’s physician(s) and the patient’s ID number.
A statement of the right to file an appeal or raise questions with a QIO about quality of care, including hospital discharge.
The name and telephone number of the QIO that serves the area in which the hospital in question is located.
A space for the beneficiary or representative to sign and date the document.
The steps necessary to appeal a hospital discharge decision or to file a complaint about the quality of care.
What Information Must the Detailed Notice Contain?
The name(s) of the patient’s physician(s) and the patient’s ID number.
The date the Notice was issued.
The date the inpatient hospital services are to end.
A statement that the Detailed Notice is not an official Medicare decision.
Specific information about the patient’s current medical condition.
The hospital and/or Medicare plan telephone number for requesting copies of documents to be sent to the QIO.
When Must the "IM" be Distributed?
The patient must receive the original IM within two days of admittance to the hospital. The hospital must obtain the signature of the beneficiary or of his or her representative and provide a copy to that person at that time. If the patient or representative refuses to sign the IM, then the hospital is required to make a note to that effect; for purposes of requesting an appeal, the date of the refusal to sign is considered the date of notification. A follow-up copy of the signed IM should again be given "as far in advance of the discharge as possible, but not more than 2 calendar days before discharge." If discharge occurs within 2 days of the date the IM was given, no follow-up copy is required.
A beneficiary may be considered discharged when Medicare decides it will no longer pay for the medical services or when the physician and hospital believe that medical services are no longer required. The Medicare Claims Manual provides that a patient may be considered to have been discharged when s/he is either physically required to leave the hospital (not merely transferred to another inpatient setting) or when s/he remains in the hospital but at a lower level of care.
Additional background on the new IM
The new notice, An Important Message from Medicare about Your Rights (IM), can be found on the CMS website at http://www.cms.gov/BNI/12_HospitalDischargeAppealNotices.asp#TopOfPage (site visited October 3, 2008). The requirements for the new notice are discussed in Guidelines which were released by the Centers for Medicare & Medicaid Services (CMS) on May 25, 2007. In the Guidance, CMS explains when and how Medicare patients must be given information about their discharge and appeal rights. See, http://www.cms.gov/Transmittals/downloads/R1257CP.pdf.
Upon receipt of a hospital’s discharge decision, beneficiaries may appeal the decision by requesting a timely review by the appropriate Quality Improvement Organization (QIO). When QIO review is requested, an additional notice called the Detailed Notice of Discharge (Detailed Notice) is to be given. CMS has issued a Question & Answer document elaborating on the use of IM and the Detailed Notice. See, http://www.cms.gov/BNI/Downloads/CMS-4105-FINAL%20RULE%20Qs%20and%20As%2004%2003%2007.pdf.
Weichardt v. Thompson, Civil Action No. C 03 5490 (N.C.Cal. 2003), was filed in federal district court in San Francisco on behalf of three Medicare beneficiaries who were forced to leave their hospitals before they were medically ready. Each plaintiff (or a family representative) objected to being discharged, but received no written notice of the appeal process for challenging the discharge decision. Neither was told that if they stayed on in the hospital, they would be personally liable for the cost of care. The plaintiffs sought a requirement that Medicare beneficiaries are given timely written notice of the reasons for their discharge and of the procedures for appealing a discharge decision.
As a result of settlement discussions, proposed regulations were published on April 5, 2006, at 71 Fed. Reg. 17052. See, http://edocket.access.gpo.gov/2006/pdf/06-3280.pdf. The proposed regulations required that a Generic Notice of Hospital Non-coverage be given to all Medicare hospital patients at least one day before a planned discharge. This generic notice would specify the date of discharge and explain the procedure for the patient to obtain an expedited review of the medical necessity for continued inpatient care. If the patient indicates that she wishes to appeal, the proposed regulations require that a detailed follow-up notice with specifics about the medical reasons for individual’s discharge be given to her by noon of the next day.
Discharge Planning in the Nursing Facility Setting
When nursing facility care needs arise, it is important to contact the local Medicare office or the Social Security office for a list of Medicare participating providers and suppliers, or check www.Medicare.gov/NHCompare.
Facilities are to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psycho-social needs that are identified in the comprehensive assessment (42 C.F.R. §483.20(b)).
Facilities are to assess the resident’s discharge potential, an assessment of the facility’s expectation of discharging the resident from the facility within the next 3 months (42 C.F.R. §483.20(b)((xvi)).
Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN)
A SNF must provide notice when it believes Medicare will not pay for an item, service, or purchase. A SNF must also provide proper notice explaining appeal rights and the recommendations for non-coverage. CMS has developed a model notice, the SNFABN, which facilities may use (Form no: CMS-10055; MCM, Pub. 100-04, Ch. 30, §70.3.1).
A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility (42 C.F.R. §483.12(a)(7)).
Resident records should contain a final resident discharge summary which addresses the resident’s post-discharge needs (42 C.F.R. §483.20(l)).
Facilities are to develop a post-discharge plan of care, developed with the participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment. This applies to discharges to a private residence, to another nursing facility, or to another type of residential facility such as board and care or nursing facilities (42 C.F.R. §483.20(l)).
Post-discharge plan of care means the discharge planning process, which includes assessing continuing care needs and developing a plan designed to ensure the individual’s needs will be met after discharge from the facility into the community (42 C.F.R. §483.20(l)).
Factors to explore in accessing whether a facility has provided appropriate post-discharge planning include:
Does the discharge summary have information pertinent to continuing care for the resident?
Is there evidence of discharge planning in the records of discharged residents who had an anticipated discharge or those residents to be discharged shortly (e.g., the next 7-14 days)?
Do discharge plans address necessary post-discharge care?
Has the facility aided the resident and his/her family in locating and coordinating post-discharge services?
What types of pre-discharge preparation and education has the facility provided the resident and his/her family?
(See, Long-Term Care and Resident Assessment Surveys. State Operations Manual Transmittal No. 8, May 1, 1999, Medicare and Medicaid: SNF Surveys, F283, F284; CMS Pub. 100-07, Appendix PP, Guidance to Surveyors for Long-Term Care Facilities).
Avoiding the Medical Improvement Trap
Skilled nursing services include observation and assessment of a patient’s medical condition. A frail or chronically ill person need not show deterioration or medical setback in order to justify skilled nursing observation and assessment, including the observation and assessment of acute psychological problems in addition to physical problems (42 C.F.R. §§409.31(b)(1)-(5); 409.32; 409.33).
The Medicare program recognizes maintenance therapy as a legitimate aspect of skilled care services provided in a SNF; that coverage cannot be denied merely because a beneficiary has no restoration potential or has achieved insufficient progress toward Medical improvement has been achieved restoration (42 C.F.R. §409.32(c)).
Notice of Admission
The Nursing Home Reform Law does not require that a facility provide a beneficiary a notice of denial of admission.
The Nursing Home Reform Law prohibits certain discriminatory admissions practices (e.g., waiving rights to Medicare, requiring written or oral assurance that the individual is not eligible for and will not apply for Medicare or Medicaid, requiring third-party guarantee of payment) and requires that facilities display prominently in the facility information about how to apply for and use Medicare benefits. (42 U.S.C. '1395i-3(c)(5)(A); 42 C.F.R. 483. 12(d)(1), (2)).
Prospective Payment and Access
As a practical matter, with respect to admissions, some nursing facilities in response to Medicare’s Prospective Payment System (PPS) for Nursing Facilities, (Resource Utilization Groups (RUG-III) criteria) are evaluating potential patients before formal hospital discharge and making admission decisions based on the beneficiary’s likely RUG-III categorization. Patients in these circumstances do not get a notice of a denial of admission and in fact may not even know that they have been evaluated for purposes of a skilled nursing facility admission.
Note: The PPS RUG-III system
does not change Medicare skilled nursing facility (SNF) criteria for
admission or services. In addition, the failure to be placed in a
high RUGs category does not automatically mean that the beneficiary
would be denied SNF coverage under Medicare. (See Pub. L. No. 105-33
(Aug. 5, 1997) §4432(a), amending §1888 of the Social Security Act,
by adding subsection (e), 42 U.S.C. §1395yy, effective on or after
July 1, 1998. See also, 42 C.F.R.'413.330 et seq.).
Transfer of Patient to Non-Skilled Bed
If the nursing facilities determines that a patient no longer qualifies for Medicare covered skilled nursing services and wishes to transfer the patient to a non-Medicare certified bed, it must give the beneficiary a transfer notice, explaining appeal rights and the steps to take to exercise the right of appeal (42 C.F.R. §483.12(a)).
Refusal of Transfer
A Medicare beneficiary has the right to refuse a transfer from a portion of the facility that is a skilled nursing facility to a portion that is not a skilled nursing facility (42 U.S.C. §1395i-3(c)(1)(A)(x); 42 C.F.R. §483.10(o)).
Bed-Hold Policies and Readmission
The Medicare law does not provide for holding beds as does Medicaid. Under Medicaid, however, when a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the facility’s bed-hold policies. The policies must be consistent with the provisions of the state Medicaid plan regarding bed-hold (42 U.S.C. §1396r(c)(2)(D); (42 C.F.R. §483.12(b)). The Medicare law does not guarantee readmission rights for a Medicare beneficiary who is hospitalized. There is, however, a right of readmission under Medicaid law for Medicaid beneficiaries who’s hospitalization or therapeutic leave exceeds the period paid by the state for bed-hold if the Medicaid beneficiary requires the facility’s services. The right of readmission is an immediate right to the first available bed in a semi-private room (42 U.S.C. §1396r(c)(2)(D)).
If a SNF decides that Medicare will no longer cover an item, service, or procedure and the facility wishes to bill the beneficiary, it must give the beneficiary written notice of non-coverage, including information about the right to request an appeal of the facility’s non-coverage decision and the steps to take to exercise that right (42 U.S.C. §1395pp (waiver of liability provisions); 42 C.F.R. §411.100 et seq.; Sarrassat v. Sullivan, Medicare and Medicaid Guide (CCH), ¶38,504 (N.D. Cal. 1989), HCFA Ruling 95-1 (Dec. 22, 1995); HCFA SNF Manual, Chapter 3, §357A (establishing when the beneficiary is on notice of non-coverage); §352.1 (determining beneficiary liability)).
If the beneficiary does not agree with the facility’s non-coverage decision, he or she may request that the SNF submit the bill to Medicare even when the facility believes that services will not be covered by Medicare. This submission is called a "demand bill" or a "no-payment bill." Demand bills are required to be submitted at the request of the beneficiary. The facility cannot bill the beneficiary for the disputed charges until the Medicare fiscal intermediary issues a formal claim determination (Medicare Intermediary Manual §3630; Sarrassat v. Sullivan, Medicare and Medicaid Guide (CCH), ¶38,504 (N.D. Cal. 1989)).
Discharge Planning in the Home Health Care Setting
Discharge planning rights in the home health care arena are not as well developed as in the hospital and nursing facility context. The appropriate focus of advocacy is on keeping services in place. Central to doing so is obtaining notice from the home health provider agency about contemplated denials, reductions, or the termination of services.
Home health agencies (HHAs) are required to give written or oral notice concerning when Medicare will pay for services and when there is a change. This notice is called a home health advanced beneficiary notice (HHABN). 42 CFR §484.10(a)(1), (2).
Effective September 1, 2006, home health agencies are to use CMS’s revised HHABN. Instructions for its use are included in CMS Transmittal 1025 (August 11, 2006), Pub 100-04 Medicare Claims Processing, Chapter 30, Section 60.
The revised notice, also referred to as R1025CP, encompasses broader notice requirements, codified in the Medicare Conditions of Participation (COP). See, www.cms.gov/transmittals/downloads/r1025cp.pdf.
HHABNs are required more frequently for reductions and terminations as a result of the court’s decision in Lutwin v. Thompson, 361 F.3d 146 (2d Cir. 2004), for example, changes in non-covered home care.
HHABNs are required in some situations where qualifying requirements for Medicare benefits are not being met, such as when there is a lack of physician orders for me care; and
HHABNs are required in many of circumstances where covered care is reduced or terminated.
Medicare provides for a two-day, expedited notice procedure to be used when services are terminated because they are no longer reasonable and necessary (see discussion below).
Notice should provide an opportunity for discussion and negotiation with the HHA, necessary appeals, and collaboration with the beneficiary’s physician.
Beneficiaries should also explore other sources of coverage when Medicare home health coverage is in question. Private health care coverage, services under the Older Americans Act, Medicaid, and other home and community-based health care may be useful options.
Advocates and beneficiaries should contact the Eldercare Locator (identified at the beginning of this writing) for an exploration of local options.
We are experiencing an up-tick in termination of services of severely ill
patients who need chronic, on-going care. Often, these patients are
expensive to treat. HHAs express concern about the cost of these
cases and about their patient mix. Many are terminating services for
"business reasons." This will be an on-going area of advocacy.
Payment and Access
The Medicare program uses a Prospective Payment System (PPS) as its methodology in paying for home health care. Under this system, HHAs are paid on the basis of a 60-day episode of care in accordance with standard payment amounts (42 U.S.C. §1395fff; 42 C.F.R. §484.200 et seq.).
The PPS for home health relies on a patient assessment instrument, the Outcome and Assessment Information Set (OASIS), as part of the process of determining the PPS amount the home health agency will be paid for each patient (42 C.F.R. §§484.210, 484.220).
When an HHA accepts a patient, it must perform an OASIS assessment of the patient (42 C.F.R. §484.250).
Each patient is assigned to a home health resource group (HHRG) based on
the combination of his or her severity levels on the three OASIS
data point elements: clinical severity, functional severity, and
Home Health Agency Requirements to Inform Beneficiaries
The Medicare program requires each participating HHA to provide its Medicare home health patients with:
Information in advance about the care and treatment to be provided by the agency;
Full information in advance of any changes in the care or treatment to be provided by the agency that may affect the individual’s well-being;
The right to participate in planning care and treatment or changes in care or treatment;
The right to be fully informed orally and in writing (in advance of coming under the care of the agency) of any changes in the charges for items or services to be provided, as well as to be fully informed of the beneficiary’s rights and entitlements under Medicare. 42 U.S.C. §1395bbb (a)(1)(A), 42 C.F.R. §484.10(c)(1) and (2).
Legal Protections Against Loss of Home Health Care Coverage
The Secretary of Health and Human Services is obligated to enforce notice and appeal rights of home health beneficiaries through several means, including intermediate sanctions and terminating the HHA as a Medicare-certified agency (42 U.S.C. §1395bbb(e)(2)).
Medicare beneficiaries are entitled to an explanation of the circumstances in which a beneficiary has the right to have a "demand bill" submitted. (CMS online manual system, Pub. 100-4, Medicare Claims Processing, www.cms.gov/manuals, Chapter 30, §50).
An expedited review process is available for a beneficiary when the provider plans to terminate services or to discharge the beneficiary.
The provider must give notice 2 days before loss of services occur.
The beneficiary must file for expedited appeal with a QIO by noon of the day of receipt of notice from the provider.
The QIO must inform the provider of the appeal, and the provider must supply the beneficiary with a more detailed notice.
The QIO has 72 hours to make a determination.
Notice Under Prospective Payment System
Under PPS, beneficiaries and their advocates should remain vigilant. Changes in health status or other patient circumstances occurring within a 60-day episode of care should trigger notice to the beneficiary.
CMS responded in its pleadings in Healey v. Shalala that notice and appeal rights are not affected by PPS; that the same notice and appeal processes currently in place apply, including the demand bill process. 186 F. Supp.2d 105 (D. Conn. 2001).
Final Reminders for Discharge Planning Advocates in the Home Health Care Setting
Advocates should work with physicians and advocacy groups to assure that detailed orders for home health care services are prepared; that physicians fully understand that physician-ordered services are not to be terminated by home health agencies without the consent of the treating physician.
Advocates should demand that home health agencies provide the HHABNs and should report agencies to the Regional Home Health Intermediary when they do not.
To the extent possible, advocates should provide physicians and home health agencies with information about Medicare coverage that support coverage when coverage issues may be questioned and before a notice of non-coverage is submitted.
Advocates should encourage patients to use the demand bill process where feasible. They should keep in mind that the issue of paying for services pending an appeal will be difficult for many beneficiaries.
When appeals are necessary, advocates should assist beneficiaries in filing an appeal of home health care coverage denials and enlist physician support in the form of detailed statements about the need for coverage.
Discharge planning in the Hospice Setting
Medicare regulations require that hospice programs perform discharge planning.
The hospice must have in place a discharge planning process that takes into account the prospect that a patient’s condition might stabilize or otherwise change such that the patient cannot continue to be certified as terminally ill.
The discharge planning process must include planning for any necessary
family counseling, patient education, or other services before the
patient is discharged because he or she is no longer terminally ill.
42 C.F.R. §418.26(d).
Appeal Rights in Hospice Discharge Situations
Section 332 of the Benefits Improvement and Protection of Act of 2000 (BIPA), Pub. L. No. 106-554 (Dec. 21, 2000), amends §1814(a) of the Social Security Act, 42 U.S.C. §1395f(a) to provide special appeal rights for beneficiaries who are at risk of discharge or termination of services from a skilled nursing facility, home health agency, or hospice. 42 C.F.R. §405.1200 et seq. The regulations require that for any termination of service, the provider of the service must deliver valid written notice to the beneficiary of the provider’s decision to terminate services. In the case of hospice patients, this notice triggers the Medicare beneficiary’s right to request an expedited determination. 42 C.F.R. §405.1202.
The regulations permit hospice programs to discharge patients under only three circumstances:
The patient moves out of the hospice’s service area or transfers to another hospice;
The hospice determines that the patient is no longer terminally ill; or
The hospice determines, under a policy set by the hospice for the purpose of addressing discharge for cause…that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired. 42 C.F.R. §418.26(a).
There are no specific appeal rights when a discharge is for cause, although the beneficiary must be notified by the hospice when discharge for cause is being considered." 42 C.F.R. §418.26(a). The hospice is, however, to:
Advise the patient that a discharge for cause is considered;
Make a serious effort to resolve the problem(s) presented by the patient’s behavior or situation;
Ascertain that the patient’s proposed discharge is not due to the patient’s use of necessary hospice services; and
Document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its medical record. 42 C.F.R. §418.26(a).
Hospice Discharge Planning Rights
Medicare-participating hospice programs must provide discharge planning, including having a:
Discharge planning process that takes into account the prospect that a patient’s condition might stabilize or otherwise change such that the patient cannot continue to be certifies as terminally ill.
Discharge planning process must include planning for any necessary family counseling, patient education, or other services before the patient is discharge because he or she is no longer terminally ill. 42 C.F.R. §418.26(d).
discharge planning fact sheets for beneficiaries and advocates
TIPS FOR BENEFICIARIES (.pdf)
TIPS FOR ADVOCATES (.pdf)
Copyright © 2010 Center for Medicare Advocacy, Inc.