The Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act’s requirements were originally set to take effect on Aug. 6, 2016; however, the Centers for Medicare & Medicaid Services (CMS) is providing 30 more days for comment on their form (not on the process) and then 90 days to implement it.

There are issues with both the form and the process. Let’s start with the process:

We do not understand the way CMS is attempting to implement this process. We think of this as we do the Important Message for Medicare (IMM). So if you are an IP, you get an IMM; if you are outpatient in observation, you get a Medicare Outpatient Observation Notice (MOON).  (But if you just come in for outpatient surgery and need to stay overnight, you don’t get anything.)

We understand that we get 24 hours for the IMM, so perhaps that is why this is being handled this way, but why is it that CMS determined that the MOON is not recommended until between 24 and 36 hours of observation? Our Medicare beneficiaries need to know right away what their status is; this is the process we follow while issuing the IMM. We need to consider this more of an informed consent. Our patients deserve to know their status right away so that they can plan for what is to come. And they also then have an opportunity for discussion  if it isn’t the right plan for them.

The intent behind the letter is to make sure that our patients understand what is in a Part B bill, and that this stay cannot be counted towards a three-day qualifying skilled nursing facility (SNF) stay. But this is only if you are a traditional Medicare patient, so make sure you know if you are or not.

Is this the correct way to communicate that? Let them come in, stay for 24 hours, and then tell them these things? CMS’s reasoning is that patients get too much information coming in the door, and this will only confuse them more. Well, what about looking at the requirements for what else the patient gets and starting to work on a more concise process that works for us and our patients – not against us.

The cost of issuing the MOON is buried in the paperwork and the employee time that it will take. There are some hospital systems considering using care management nurses and social workers to issue these forms. Please consider the following before you just volunteer that department to take on this process, however:

  • The practice of obtaining a signature on a form, then making copies, and making sure copies are in the chart can be handled by someone other than care management.
  • Requiring that care management handle these forms takes precious time away from what such personnel should be doing, which is advocating for our patients (no matter the insurance costs) to make sure they get the best, safest, most evidence-based care with a focus on what matters to them and their goals.
  • Care management should handle any and all discharge appeals, but this is such a different part of the process than providing notices and obtaining signatures, making copies, and putting copies in the chart. There is no appeal for observation status, so there should be no reason at all for them to get involved with the initial process.

The state of New York already had the requirement to educate Medicare patients about observation. Did CMS ever call them and ask what works and does not work? Why are we reinventing the wheel when we can steal with pride from states that already figured this out?

And now for the form itself: why did they leave this open-ended part of the MOON in? “You’re a hospital outpatient receiving observation services. You are not an inpatient because…”

While it appears they may want a clinical picture painted for the patient in that comment box, I think we need to leave the clinical conversation with the care team and patient and family, not on a piece of paper. Our organization has decided to use CMS wording for the explanation. After all, isn’t that what we should do? Ours will read: “according to Medicare rules, we do not expect you will need hospital level of care services for more than two midnights.” 

In terms of the process that Trinity Health will follow when we do start to implement this nationwide, I have to acknowledge our revenue and IT teams and thank them for helping us. Patient registration will take point on issuing the MOON. And kudos to our IT team, which already worked on having the form printed for us (we are just waiting for the final approved document) with patient information therein so that the patient will know it is theirs. In some of our organizations we have electronic signatures available for our patients, so that will remove the step of having to scan in the document. 

I still think there is a bigger issue here, and one we are trying to tackle: who changes the form that the patient gets when there is movement from inpatient to outpatient/observation and outpatient/observation to inpatient? That will be our bigger challenge in the long run.  And this is where I think the care management team will be instrumental in the process, utilizing their expertise in the Condition Code 44 process. Although CMS does not discuss whether, if a patient gets written notification of CC-44, they also need a copy of the MOON.

More on this is to come, I am sure!

About the Author

Mary Beth Pace is vice president of care management at Trinity Health.

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