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Tips for handling Medicare discharge appeals
New rules and guidelines for Medicare Discharge Plan Appeals — known officially as the "Important Message from Medicare about Your Rights" (IM) — require hospitals to respond to appeals at any time, including weekends and holidays. In order to be prepared, hospitals need to identify the right people and have the proper measures in place. Here is a checklist to consider:
1. Broaden the circle of contacts. Under the latest rules, when a patient initiates a Medicare discharge plan appeal, medical records must be copied and delivered to the pertinent Quality Improvement Organization (QIO) office on the next calendar day. In order to respond to that quickly, the circle of people involved in responding to the appeals and ensuring that information is gathered and delivered in a timely fashion must be broadened to include case managers, nurses, social workers, medical records, and so forth.
2. Set a clearly delineated process. Determine a step-by-step flow of information so that all parties know what they have to do.
3. Identify key roles, not key people. Rather than relying on particular individuals to carry out specific functions, key roles should be identified, regardless of who is on duty on a particular day. For example, medical records may have four or five people who regularly cover on weekends. All of them must know what is required in case records have to be copied and delivered outside of regular business hours.
4. Educate everyone involved in the process. The best way to promote cooperation is to make sure that everyone understands the importance of following procedures. It is particularly important to get the buy-in of managers and department heads who will then communicate this priority to their staff.
5. Identify possible weak points. Even with the best response plan, there will be failures. (For example, the courier that is used on weekends does not work when a major holiday falls on a weekend.) The more potential weak points that are identified, the better the chance of responding successfully to the unexpected.
(For more information on the new notice and guidelines from the Centers for Medicare & Medicaid Services, see the web site at www.cms.hhs.gov.)