Healthcare Compliance Forum
Quarterly Insights
Summer 2007

During the past month, the Healthcare Compliance Forum has been focusing on how compliance professionals are implementing the rule, effective July 1, 2007, requiring hospitals to deliver a revised version of the Important Message from Medicare to inform Medicare inpatients about their hospital discharge appeal rights. In a peer-sharing conference call held Aug. 23, and with the Quarterly Insights question posed below, we gave the Healthcare Compliance Forum members the opportunity to share their thoughts on delivering the Notification of Hospital Discharge Appeal Rights. (Members were given the option of being published anonymously.)

We asked Healthcare Compliance Forum members this question:

Are you having difficulty with patients refusing to sign the notification? If so, what do you do? If not, what successful strategies have you implemented to ensure patient notification?

And here is what you told us:

Last week I had the privilege of facilitating a call on this topic with 12 of my peers in the Healthcare Compliance Forum. The issues fell naturally into three categories: issues with delivering the notice, problems related to the Quality Improvement Organization and compliance issues. We were fortunate to have Marla Brady, Harrison Medical Center, Bremerton, Wash., whose response appears below to talk through the challenges in implementing the rule. Members from Alabama, Georgia, Kansas, New York City, North Carolina, North Dakota, Utah, Washington, and Wisconsin participated on the call.

Biggest take-aways:

*           Everyone is so willing to share their pain--it's great for learning!

*           As expected, facilities are at various levels of compliance and awareness.

*           There are concerns about subsequent audits by CMS, but no one knows what to expect or how those audits would be triggered.

*           The difficulties with meeting this requirement are compounded for facilities that do not have weekend case management or an electronic medical record.

*           Only two facilities have been challenged with an appeal so far, so there have not yet been many experiences to draw from.

*           The biggest surprise was that the conversation was so lively; it went longer than the allotted time. All in all, it was a good call with active participation.

I'm looking forward to our next call on the topic of present-on-admission status and gaining more insights like these from my peers.

Barbara S. Viskochil

University Health Care - Hospitals and Clinics

At Harrison, our experiences have included:

*           Confusion in general by Medicare patients about the overall message and appeal process

*           Much staff time spent in hospital process redesign to achieve the seven-day-a-week ability to deliver the second Important Message document and to respond to appeal requests in a high-quality manner

*           Challenges for the organization to obtain signature/acknowledgment when the patient is not capable and to repeat the process with the second Important Message days later

Also, we were challenged by a single internal telephone number to place on the Important Message where patients could get more information about the message 24/7; how did other hospitals address this?

We have found that our QIO refuses to give a concurrent written determination with an appeal; instead, it gives us a verbal determination, and then a written determination follows many days later (has been an average of seven days for the written determination). We had to implement an internal process to ensure that the verbal QIO determination is received by those who need it. I find this unsettling. Since hospitals are so held to written concurrent documents (e.g., the Detailed Notice of Discharge), why is the QIO not held to the same documentation?

To date, the few appeals have resulted in all QIO agreements that the patient was ready for discharge. Has all this effort and resource consumption added value to our patients?

James S. Rowson, FHFMA, CPA

Harrison Medical Center

We are not seeing an issue with individuals not wanting to sign it. We see the bigger issue as being very labor intensive as we try to meet the standards. Some days it has taken up to six hours to complete the process with all of the Medicare patients we see.

Cathy Jesus, MSW, CSW

Creighton University Medical Center

We have encountered a patient refusing to sign the notification only two or three times. Most Medicare patients are already used to signing extra paperwork for their admissions. But we have found an issue with calling the patient's next of kin or personal representative to read the information to them over the phone. Most have indicated that they do not have time to listen or do not care about hearing the information. Even when we have the patient or representative in front of us, some still have difficulty fully understanding what we are explaining even though we are speaking very simply and the notice is in simple language. We do our best to inform the patient or representative of the patient's right, document the interaction, and when done over the phone, mail the copy to the representative as required. The admitting department is responsible for the initial notification, and our case managers are responsible for following up with any further notices that need to be issued on the patient floor. We have incorporated auditing this for compliance as one of our quality indicators measured in the case management department, which will be reported to the corporate compliance committee.

William F. Wyman, MS, FACHE, CHAM

Lowell General Hospital

Our biggest difficulty has been determining the department responsible for getting the patient's signature. Ideally, it should rest with case management, but our case managers are not here on weekends, so it has fallen to patient access staff to get the signatures. The staff in patient access (admitting) does not have up-to-date information on the clinical status of the patient, so they cannot anticipate the discharge date. Other issues that we face include:

*           Many times, trauma patients are not seen by a registrar prior to admission. In these cases, who facilitates the delivery of the first and second letters?

*           When a patient's appeal is either upheld or denied, what billing measures do other hospitals have in place to ensure that proper coding and modifiers are added prior to a bill drop?

I hope this is helpful.

Anonymous

Register today for the next Healthcare Compliance Forum members-only peer sharing conference call

The Quality Initiative and Present-on-Admission Coding

Sept. 12, 2007, 2:00-3:30 p.m. CDT

Register today for a peer-sharing conference call on POA led by Gloryanne H. Bryant, Corporate Director, Coding Compliance at Catholic Healthcare West in San Francisco.

During this call, you will share with your peers what your facility is doing to comply with the quality initiative, hospital-acquired infections, and present-on-admission coding. The purpose of this event is to bring together members of the Healthcare Compliance Forum to discuss hospitals' initiatives to connect their quality review process, diagnosis coding process, and compliance procedures in light of the recent quality initiatives and other developments such as ICD-10 implementation and the FY08 inpatient PPS proposed rule.

 
A Roadmap to a New Healthcare Workforce Model
Sept. 10, 2007, 2:00-3:45 p.m. CDT

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