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Coordinating Important Message notifications
Rules require immediate response
By Vivian Campagna, MSN, RN,C, CCM
Commissioner, Commission for Case Manager Certification (CCMC)
New York City
On Monday, July 2, 2007, a Medicare patient in a metropolitan hospital, whom we'll call Mrs. Jones, was notified by her physician that she was to be discharged the next day. In accordance with new rules governing the rights of Medicare patients, Mrs. Jones already had been informed twice — once at admission and again within 48 hours of anticipated discharge — of her right to appeal.
That evening, despite the physician's determination that she was ready to go home, Mrs. Jones decided to exercise her rights as a Medicare patient to appeal her discharge plan. Although Medicare patients have had the right to appeal discharge plans for many years, new rules that went into effect just a few days before (on July 1, 2007) complicated matters for the hospital.
Under the new rules, known as "An Important Message from Medicare about Your Rights" (or "IM"), Medicare patients have until midnight of the day of discharge to appeal — meaning to request a review by an outside Quality Improvement Organization (QIO). Furthermore, the new rules state that the QIO must receive clinical information for review (in many cases, a complete copy of the patient's medical record) by noon the next calendar day — not the next business day — even if it falls on a Saturday, Sunday, or holiday.
In Mrs. Jones' case, her decision to appeal her discharge meant that her medical records had to be copied and delivered on July 4, a national holiday, to the local QIO office. Although the QIO office was staffed on the holiday, it was located in a building that was not open that day. (Fortunately, a member of the hospital staff lived near the QIO office and volunteered to deliver the records personally on July 4. The staff member, having previously contacted the QIO, knew that she had to ring the buzzer to the building and wait several minutes for someone from the QIO office to come to the door and accept the records.)
Contingency plans should be in place
As the example of Mrs. Jones' case shows, the new Medicare discharge appeal rules create scenarios in which hospital staff may have to scramble to make sure that there are people assigned to specific tasks and available 24/7, including on weekends and holidays. Rather than wait until they are confronted with an appeal made over a major holiday — or perhaps one that falls on a weekend — hospitals should have detailed contingency plans in place to respond to any possibility.
For example: Medical records must have personnel present and/or available seven days a week, 365 days a year to copy records for QIO reviews. Even if the hospital is notified of a Medicare discharge plan appeal on a Saturday, the records must be copied and available for delivery by noon the next day. There is no waiting until the next business day.
Hospitals must have several designated liaisons with the local QIO — and not just one person. Those liaisons should be responsible to be contacted by the QIO, and know how to facilitate delivery on weekends and holidays.
Because of the new Medicare appeal rules that require immediate response, hospitals must widen their circles of communication and cooperation across several departments. Those may involve case management, medical records, nursing, social work, and registration.
Cross-department cooperation already is part of the case management process, with hospital case managers facilitating communication among physicians and other clinicians, nursing staff, the patient and/or family, insurance companies, and other interested parties as well; further, given their responsibility for discharge planning, it is only logical that case managers are integral parts of the hospital's Medicare appeals response team.
"There is a need for better communication all the way around, especially to make discharge as safe as possible for patients," observed Susan Bailey, regional vice president and CEO of The Specialty Hospital of Washington. "When a patient no longer meets medical necessity, the physician, as the driver of the team, works very closely with case management and other members of the interdisciplinary team. It's more important today than ever before."
For hospital-based case managers, Medicare appeals add further complexity to the overall discharge planning process.
For the hospital case manager, discharge planning begins as soon as the patient is admitted in order to prepare for a successful transition, whether to another treatment facility (such as rehabilitation) or to home. As the Medicare IM informs patients: "During your hospital stay, the hospital staff will be working with you to prepare for your safe discharge and arrange for services you may need after you leave the hospital. When you no longer need inpatient hospital care, your doctor or the hospital staff will inform you of your planned discharge date."1
The goal of a safe and successful discharge plan is to help the patient adhere to physician orders for treatment, prescriptions, and other concerns such as special diets. There are no guarantees, however, that patients will adhere to physicians' orders. It may be that, despite the family's assurances, the patient does not have access to transportation to the doctor's office for follow-up visits.
To give another example, following cardiac surgery, the postoperative plan recommends that a patient recover at a rehabilitation facility to regain further function. However, the patient says she wants to go home and will receive care there. Because the family is only able to provide care for 12 hours a day, to make up for the gap, the hospital case manager helps arrange in-home care.
However, within 30 days of discharge, the patient is back in the hospital and the readmission is flagged. As the case manager investigates, it becomes clear that the reason for the readmission is the patient refused to allow the in-home care provider to enter her residence. The patient later tells the case manager she "didn't want to let a stranger into the house."
As this example illustrates, despite the best discharge planning, when working with the wishes of patients and families, the plan may not be followed. All too often the result is patients are readmitted.
Adding another potential complication to discharge planning, hospital-based case managers must also include in their processes the possibility that Medicare patients may file appeals. Further, under the new appeals rules, hospital case managers will likely play a key role in making sure that patients receive two notifications as required and that a system is in place to handle appeals to a QIO, even on weekends and holidays.
The IM procedures exist to guard the rights of Medicare patients who have legitimate concerns about being discharged. As the IM states, if patients feel they are being discharged too soon, they may talk to hospital staff, physicians, and managed care plans, if they are covered by one. If they decide to pursue an appeal, they must contact the QIO no later than the planned discharge date and before they leave the hospital. By following these steps, patients will not have to pay for services received during the appeal, except for charges such as copays and deductibles.1
The patient's decision to appeal may be made any time before discharge. That means when a Medicare patient receives a second IM notice the day before discharge he may give every indication that he will go home the following day. However, if the patient wakes up at 3 a.m. on the day of discharge and does not feel well, he may decide at that point that he is going to file an appeal.
Once that occurs, all involved parties must respond. From a hospital throughput standpoint, a bed that was expected to be vacated that day will now be occupied. Procedures that were previously established must now be set in motion to have medical records copied and delivered as soon as possible.
With the new Medicare rules, the patient appeal process has moved out of the time frame of Monday through Friday. As a result, hospitals must respond with a wider circle of people who must be involved in the Medicare appeals response process.
Every department needs to know their responsibility, from patient notification to ensuring the records are copied and able to be delivered — on any given day — to the QIO for review. Preparing a response plan means choosing the right players, identifying potential weak spots, and providing the checks and balances. The goal is to ensure that appeals are handled properly and within the required time frame, and that potential challenges — such as delivering medical records on a national holiday — are anticipated with an appropriate response plan.
Vivian Campagna, MSN, RN,C, CCM, is a commissioner of the Commission for Case Manager Certification (CCMC), the first and largest nationally accredited organization that certifies case managers. She also is director of patient care management at Lenox Hill Hospital in New York City, where she supervises a staff of 21 case managers, 12 social workers, three discharge planning associates, three denials and appeals coordinators, and two payer specialists.