Doctor showing digital tablet to elderly patient in hospital bed

You have questions, we have answers.

EDITOR’S NOTE: On Jan. 24, RACmonitor published a special bulletin authored by Dr. Hirsch on the manual changes to the instructions for the delivery of the Important Message from Medicare (IM). There were several outstanding questions which Dr. Hirsch responds and shares with readers.

First, I have to say I so appreciate the staff at the Centers for Medicare & Medicaid Services (CMS) who work in the beneficiary notice division. They address my questions quickly, although occasionally they answer with that special language that CMS uses that makes you stop and think twice about what they are trying to say.

Now here are the key answers to my questions (paraphrased for clarity).

Question- Does there need to be a discharge order in the chart for the BFCC-QIO to accept the appeal?

Answer- No, there does not need to be a discharge order in the chart when the patient requests an appeal, but the notes should indicate the patient is stable for discharge.

Question- We are required to deliver a second copy of the IM if more than two calendar days have passed since the first issuance. That follow-up copy does not require a signature. Is it sufficient to simply make a copy of the original IM and hand that to the patient, noting in the record that it was provided to the patient?

Answer- You must retain a copy of the follow-up IM that was provided to the patient with a notation on the copy of the date that it was delivered, such as in the Additional Information section. The patient does not need to sign this follow-up copy. It is only if you deliver a “new” IM as the follow-up copy that the patient must sign and date it. In that case, of course, you must retain a copy of this IM.

Question- If you deliver the original or follow-up copy on the day of discharge, we still have to offer four hours for the patient to think about appealing. Are we required to keep the patient four hours before allowing them to leave?

Answer- No, if the patient agrees to the discharge, they do not have to stay the full four hours. You should note that four hours was offered to the patient.

Question- When delivering to a representative via telephone, that person often requests that their copy be left at the bedside and they will retrieve it at the next visit. Is this adequate for delivery to the representative?

Answer- No, if you have to deliver the IM to a representative who is not present, even if you call and verbally explain it, you must still send them a copy via USPS, FedEx, UPS, secure fax or email, and get proof of delivery. You can leave a copy by the bedside but that alone is not enough.

(I wonder… if the representative sends you a selfie of them picking up the copy at the bedside would that be acceptable?)

Question- Patients have until midnight to file a timely appeal but hospital staff trained in delivery of HINNs are not in the hospital at midnight. What do we do?

Answer- If the patient has not appealed when the appropriate staff is close to going home, a completed HINN 12 may be delivered to the patient indicating financial liability will begin the next calendar day. If the patient subsequently files an appeal before midnight, that HINN 12 will be invalid, and liability cannot be shifted to the patient. In that case, the QIO will contact the hospital, request delivery of the DND to the patient, request records, and so on. If the patient appeals after midnight, the appeal is considered untimely. The QIO will accept the appeal and review it. If the QIO rules in favor of the hospital, the patient liability will begin as indicated on the HINN 12.

Programming Note: Listen to Dr. Hirsch every Monday as he makes his rounds on Monitor Mondays at 10 Eastern, sponsored by R1 RCM.

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