Updates on Peer-to-Peers, Patient Notices, and Post-Acute Care

You are probably aware that many Medicare Advantage (MA) plans are claiming that due to new rules issued by the Centers for Medicare & Medicaid Services (CMS), they are unable to allow peer-to-peer (P2P) discussions. Well, I asked CMS if this is true, and they stated that “CMS-4208-F did not prohibit plans and providers from engaging in voluntary P2P.” CMS also told me that after a denial is issued, an MA plan may reopen the determination if they have received additional information and can approve the case. Now, how would they receive such information? Via a peer-to-peer discussion.

Moving on, as everyone has heard from me countless times, the Medicare Outpatient Observation Notice (MOON), Important Message from Medicare (IMM), and Detailed Notice of Discharge (DND) are all expired, and CMS has told providers to continue to use the expired versions until the new versions are released – and then there will be a 60-day grace period. Well, a hospital recently had a Medicare patient who appealed their discharge, was given the DND as instructed by the Quality Improvement Organization (QIO) representative, and a copy submitted to the QIO with the medical records.

The QIO then contacted the hospital and told them they cannot hold the patient financially liable since the DND was expired. The hospital explained that there is no current version, but the QIO was not swayed. Several calls and two days later, a supervisor finally relented, apologized, and explained that they will be providing education to their staff.

In other QIO news, Acentra recently had a webinar about patient appeals of discharges from skilled nursing facilities (SNFs), and the data they presented was both eye-opening and exactly what one would expect. As some may know, when a Medicare or MA patient receiving skilled care is to be discharged, the facility must give the patient a Notice of Medicare Non-Coverage, which is similar to the IMM for hospital inpatients. They reported that 93 percent of the discharge appeals they received were from MA patients when the MA plan notified the SNF that coverage was ending, and in 48 percent of those cases, the QIO sided with the patient in agreeing that skilled care was still necessary.

They also reported that when the QIO sided with the patient, that process repeated over and over, with the MA plan again stating that coverage was to end and another notice provided to the patient. In fact, one patient received 12 such notices, meaning the QIO ruled in favor of the patient 11 times that skilled care was still needed after the MA plan tried to terminate coverage.

Now, it is important to note that there is less-than-ethical data on both sides, as it has been shown that when patients are in SNFs under Part A, the most frequent day of discharge is on day 20, when the 100-percent coverage provision by Medicare stops and the facility must start billing either the patient or their supplement for the daily copayment. We all need to do the right thing and let the money fall where it does.

And on the subject of post-acute care, I recommend everyone get a copy of an article titled “Navigating Post-acute Care Options for Patients After Hospital Discharge” from JAMA Internal Medicine. It is a great review of the requirements and capabilities of home care, SNF, inpatient rehabilitation facilities (IRFs), and long-term acute-care hospitals (LTACHs). Now, before anyone starts to scream at their computer screen as they read this, I did write to the lead author and point out that IRFs and LTACHs are not post-acute care settings, but are in fact considered acute care; but he said the journal editor asked them to use that terminology to avoid confusing doctors. I will note that the article includes a great table with the details for each setting and a great flowsheet to help determine the correct setting for a patient. If there is a paywall, ask your hospital librarian to get a copy for you.