One cannot place liability on the patient without a safe discharge plan in place.
Case management takes on many roles within the hospital setting, but one scenario that typically makes us stop and pause (and maybe add a sigh) is the process required when a patient appeals their discharge. The questions that follow may begin with:
- What are our next steps?
- Is the patient required to begin payment for the stay?
- Can we discharge the patient during the appeal process?
- How will the hospital be notified of the appeal determination?
Let’s discuss these questions and solutions to prevent or simplify this seemingly painful process. To begin with, the Hospital Issued Notice of Discharge (HINN-12) process is utilized as the tool and resource for Medicare patients who may be appealing their discharge.
Medicare has given us the HINN tool to be used for reimbursement of a continued hospitalization, after the patient refuses a safe discharge in place. If the patient loses their appeal with the Quality Improvement Organization (QIO), the patient will become financially responsible for the continued stay. This process applies to any patient who qualifies for the Important Message from Medicare (IMM), including Medicare Advantage (MA) plans, Medicare as a secondary payer, or dual-eligible (Medicare/Medicaid) recipients.
Commercial payers may not have an equivalent tool or a concurrent review after a discharge appeal that leads to the patient being financially responsible. Often, these patients remain in the hospital past their discharge date, leaving the hospital without the ability to enforce a discharge or financial responsibility for the continued stay. The HINN-12 process should be seen for what it is: a great tool to keep the discharge process moving while continuing to work with the patient and family to agree to a discharge plan.
Step 1: The Medicare patient has appealed their discharge or there is an expectation to appeal.
The day has come! Case management has worked hard and has an accepting skilled nursing facility (SNF) or post-acute placement plan in place for the discharge today. The hospitalist has either written a discharge or the intent to discharge (the initiation of the appeal process no longer requires a written discharge order). The first question that I always ask the case management team is, “why is the patient appealing?” It is likely that the patient and/or family has an unmet need or fear that is driving the appeal. My recommendation is to get to the bedside ASAP and bring your listening skills before they call 1-800-MEDICARE. Patients and/or their families are likely appealing the discharge related to a fear they may have based off an unmet need, whether it’s realistic or unrealistic. They may have had a spouse die at a SNF or have heard that people that go to a SNF, but never go home. They may be afraid to let home health into their home or they may feel safer in the hospital due to their lack of home support.
Regardless of the reason or the validity of the fear, the concern is real to them. Listening and working to resolve concerns can prevent the appeal from occurring. A different SNF closer to family may make them more comfortable. Maybe accommodation can be made for a family member to stay with the patient in the facility to ease the transition. I would estimate that case management visits to ensure a collaborative discussion and patient transition will help avoid a discharge appeal, and it is well worth case management’s time to enhance the patient’s satisfaction level with the discharge.
Step 2: The patient has appealed. What do we do now?
Ok, the patient has appealed, so on to the next steps. Maybe you have not had a Medicare appeal recently, or maybe you have never handled one. What will happen next? Well, your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) is going to reach you by the method your hospital provided to them.
The two QIO organizations are Kepro and Livanta, and they are assigned by state. The QIO has a designated contact at your facility where they will send the appeal letter and required document request. The requested documents need to be returned to the QIO within 24 hours. Due to this timeline, the method by which the QIO letters come in should be monitored by someone in case management at all hours that the department is operating. If the requested documents are not returned by the hospital to the QIO in the requested timeframe, the QIO will agree with the patient on the appeal. This will prevent the hospital from proceeding with the HINN process or attributing financial liability to the patient, thus limiting the hospital’s ability to move forward with discharge.
The documentation request from the QIO will include the IMM that was signed by the patient and a copy of the signed Detailed Notice of Discharge (DND). The DND letter can be found on the Centers for Medicare & Medicaid Services (CMS) website and must be given to the patient when they appeal to the QIO. On the DND notice, you will indicate why the patient’s hospital stay is no longer required and why Medicare payment for their stay is ending due to lack of medical necessity.
To proceed with the discharge appeal process, case management must ensure that there is a safe discharge plan in place throughout the appeal process. If at any time the safe discharge is no longer available, the patient will remain in the hospital. An example would be that the patient is expected to discharge to a SNF and the bed is no longer available, and there is no other safe discharge backup option in place. You cannot place liability on the patient without a safe discharge plan in place. One of the most common questions asked is this: is the patient required to remain hospitalized during the appeal? The answer is yes. The appeal occurs because the patient feels they are not ready for discharge, therefore they remain in the hospital until the appeal is complete.
Step 3: Your QIO agrees that the patient is appropriate for discharge. What happens now?
The QIO has 24-48 hours to make a decision on the appropriateness of the discharge. My experience has been that in most cases, if you have submitted the documents they have requested and confirmed a safe discharge plan, the QIO will side with the hospital. Once you receive the QIO decision, you can inform the patient that their responsibility for the hospital bill will begin on the following day at noon, if they have not been discharged from the hospital by that time. The letter provided to the patient should outline the reason they no longer meet medical need for inpatient hospitalization, the date upon which they will be financially liable, and the estimated total or average daily cost, beginning from the date of noncoverage. This letter must be signed and dated by the beneficiary. If they refuse to sign it, you can indicate that on the form. This can be a difficult conversation to have with a patient and/or family. My approach has been to take the manager/director of patient billing along to meet with the patient. They should bring information on the expected daily costs to begin the next day at noon. Be sure to have conversations with your leadership once this HINN-12 process begins. There will likely be lots of discussion prior to asking the patient to pay for their stay regarding how your organization will decide to handle that sensitive topic.
Step 4: What? A second- and third-level appeal?
Yep! A patient has the right to a second- and third-level appeal if they continue to refuse the discharge plan. But after the patient loses the first-level appeal, the financial liability falls onto the patient if they choose to remain in the hospital. The second-level appeal process for Medicare Fee-for-Service (FFS) will take 1-3 days for a response, for a hospitalized patient. The medical record review will be the same information as submitted on the first version, but will be reviewed by a different physician than during the first appeal review. On the second review, the family is permitted to submit pertinent documentation. A second-level review for a MA plan may vary, dependent on the payers. Reach out to the MA plan on all appeals to verify their appeal process and documentation requirements.
The third-level review will occur as an Administrative Law Judge (ALJ) hearing. The office of Medicare Hearings and Appeals (OMHA) is responsible for administering ALJ hearings. MAXIMUS is the Federal Services for the Part C Independent Review Entity (IRE). Any party in the appeal process may appeal to the Medicare Appeals Council if they are dissatisfied with the outcome of the ALJ decision. To dig into more details on these higher levels of appeals, go to https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/BFCC-QIO-Review and dive into the QIO manuals and everything related to the appeals process.
Hospitals should have an outlined policy for how they address patient appeals, as case managers will want to ensure that they are trained regularly regarding this process. Patients appealing their discharge should not be a hospital common occurrence; however, we are seeing it occur more frequently in our collaborative health systems across the country.
Reviewing these cases will be helpful to make sure that the necessary steps are taken to ensure compliance, and to see if this could be avoided in the future.