Same old New MOON, but potential problems appear in two of the other three new forms.

All federal forms require periodic review and reapproval by the Office of Management and Budget (OMB). The approval is indicated on the form by a unique number and an expiration date. The Centers for Medicare & Medicaid Services (CMS) recently announced the submission of three new forms in the Federal Register, as required by law, and their submissions to OMB indicated that there would be no increase in burden to providers.

But a review of two of the three new forms paints a very different picture. First, the good news is that the Medicare Outpatient Observation Notice (MOON) has not changed, except for the expiration date. (Note that if you downloaded the PDF version of the MOON on the first day it was posted, Jan. 9, 2020, the expiration date was wrong; it has since been corrected). But both the Important Message from Medicare (IMM) and the Detailed Notice of Discharge (DND) have undergone significant revisions, and when asked about this, Dr. Ronald Hirsch, Vice President of R1 RCM, remarked that “fortunately, these new forms are not required until April 1, because it is far from clear how these are to be completed.”

In the case of the IMM, there is a section with instructions for patients if they miss the deadline to appeal their discharge. Within that section, it advises patients with Medicare to call the Quality Improvement Organization (QIO) whose name and number are on every form. But for Medicare Advantage (MA) patients, the prior instruction was simply to “call your plan.” The newly approved form now indicates “call your plan at….” with a blank space that must be completed by the hospital, with the “plan name and toll-free number.”

The instructions for completion of the IMM refer to this point, stating that “the plan’s name and contact information must be displayed here for the enrollee’s use in case an expedited appeal is requested, or in the event the enrollee or QIO seeks the plan’s identification.” Yet there is no indication where the hospital should get this information. Every Medicare Advantage patient is issued an identification card with a member services number, so while it seems that information can be transferred to the IMM, it is unclear if that is specific enough.

Performing this additional task, while seemingly simple, will add to the burden of completion of the IMM, especially in the case of patients who have enrolled with a Medicare Advantage plan, but do not carry their card or are even unaware of the plan’s name, much less a contact number. Yet CMS did not indicate this added burden in its submission. 

In the case of the DND, the added burden is substantial. The prior DND, which is presented to the patient after the QIO has acknowledged receipt of a discharge appeal, required the hospital to indicate the specific medical conditions present and place a checkmark indicating that “Medicare does not cover inpatient hospital services that are not medically necessary or could be safely furnished in another setting. (Refer to 42 Code of Federal Regulations, 411.15 (g) and (k)).” The new form requires the hospital to indicate “the facts used to make this decision, a detailed explanation of why the hospital stay is no longer covered, and the specific Medicare coverage rules and policy used to make this decision.”

“It seems that if 42 CFR 411.15 (g) and (k) were the specific references used by CMS for the many years that the old DND was in use, the same reference should be sufficient now,” Hirsch said. “But will CMS, and more importantly, the administrative law judges, agree if the patient appeals after the fact? If not, what reference should a hospital use? In almost all cases, the patient continues to require medically necessary care, but that care can be provided in a lesser setting than an acute-care hospital.”

“If I had to add another reference, I would use 79 FR 50945, where CMS says ‘the crux of the medical decision is the choice to keep the beneficiary at the hospital in order to receive services or reduce risk, or discharge the beneficiary home because they may be safely treated through intermittent outpatient visits or some other care,’” Hirsch added. “That nicely summarizes the decision that every doctor makes every single day a patient is hospitalized, asking if they are able to safely receive care in a lesser setting. When the answer is ‘yes,’ then a discharge order is written.”

This seems to indicate that the burden on hospital staff is certain to increase, yet, again, CMS indicated to OMB that the changes will add no burden. Likewise, these changes are substantive, and the little read notice in the Federal Register, with no way to access the proposed form, seems to have disregarded the rights of the provider community to comment on these changes. Time will tell if CMS adds information to guide hospitals prior to the April 1 deadline. 

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