June 10, 2015

Hospital Discharge Rights and Appeals

Presented by:

The SHIP National Technical Assistance Center

Resources for Today’s Webinar• Available for download in the pre and post webinar emails

from WebEx• Also available in the password-protected area of

www.shiptacenter.org in the “Center Services” menu:> Login > Center Services > Events > Event Archives

Note: You must have a SHIP Staff account to download from the password-protected “Event Archives”

Today’s Speaker

Kat FitzpatrickEducation Coordinator, Medicare Rights Center and SHIP National Technical Assistance Center

What we will cover today

Medicare rules

related to hospital

discharge

When beneficiaries

receive hospital discharge plans

How discharge plans are

developed and implemented

Appealing hospital

discharges

Medicare coverage of

post-hospital

care

Medicare coverage of hospital care

Inpatient

•The beneficiary has been formally admitted as an inpatient into the hospital by an attending physician

•The beneficiary’s care is expected to last at least two midnights

•Medicare Part A covers most medically necessary inpatient hospital care

Medicare coverage of hospital care

Outpatient

•The beneficiary has not been formally admitted into the hospital by an attending physician

•The beneficiary’s care is expected to last less than two midnights

•Medicare Part B covers most medically necessary outpatient hospital care

Medicare coverage of hospital careWhy is the inpatient vs. outpatient distinction important for beneficiaries?

oOriginal Medicare will cover post-hospital Skilled Nursing Facility (SNF) care if the

beneficiary has had at least a 3-day qualifying inpatient hospital stay and enters

the SNF within 30 days of leaving the hospital

oCosts may be higher for beneficiaries who receive outpatient hospital care, as

opposed to inpatient hospital care

oOutpatients may also experience difficulty getting discharge plans and discharge

planning services, since Medicare does not require that outpatients receive these

services

Note: Medicare Advantage plans may or may not require plan members to havea 3-day qualifying inpatient hospital stay in order to receive covered, posthospital SNF care

Medicare Rules for Hospital Discharge

Medicare hospital discharge guidelines • Hospitals should work with beneficiaries and their caregivers to

plan for hospital discharge

• Hospitals must provide names of Medicare-certified SNF and home health agencies to beneficiaries before they are discharged

• To compare the quality of these providers, visit www.medicare.gov or call 800-Medicare

• Hospitals must provide the Important Message from Medicare Notice to beneficiaries

• Provided upon admission and again before discharge

• Explains beneficiary rights

• Explains hospital rights to appeal a discharge

Discharge planning requirements• Discharge planning requirements for inpatients:

All hospitals must screen inpatients to identify those who are at risk for complications without a discharge plan

o Hospitals must provide a detailed discharge plan if:

The inpatient is screened and found to be at risk for complications without a discharge plan

The inpatient’s physician requests discharge plan

OR

The inpatient or caregiver requests a screening, and the screening finds that a discharge plan is needed

Discharge planning requirements

• Discharge planning requirements for outpatients:

Hospitals are not required to provide discharge planning to outpatients

Discharge planning timeline

Note: Medicare will not penalize hospitals as long as the identification process for inpatients that likely need discharge planning occurs at least 48 hours prior to the beneficiary’s discharge and as long as there is no evidence that the planning was delayed due to the hospital’s failure to complete it on a timely basis

• Discharge planning timeline requirements for inpatients:

o Screen inpatients at an early stage of their hospital stay to identify those needing a discharge plan

o If the beneficiary’s stay is less than 48 hours, hospitals still need to screen them for discharge planning prior to their discharge

o If a beneficiary’s condition worsens and later requires a discharge plan, hospitals must provide one

Discharge planning timeline

• Discharge planning timeline requirements for outpatients:

o Medicare does not require that outpatient care, such as that provided under observation or in the ER, receives a discharge plan

The discharge planning evaluation and plan

• Discharge planning must be completed by qualified hospital staff, e.g., nurses, social workers, physicians, therapists

A discharge planning evaluation assesses:

•Biopsychosocial needs•Information from beneficiary and caregivers, including preferences and health care goals, capacity for self-care and availability of caregivers and insurance coverage

•Feasibility of return to pre-hospital environmentAnd • Access to insurance coverage for post-hospital care

The discharge planning evaluation and plan

Post-hospital care options offered depend on:

•Beneficiary’s preferences and health care goals•Beneficiary’s capacity for self-care or access to capable caregivers

And•Availability of appropriate services and facilities after a hospital stay, including SNFs, HHAs, and community-based services

Implementing a discharge planCMS Requirements for Hospital

•Written instructions •Updated medication list •In-hospital training•Transfers to post-hospital care •Referrals to home health or hospice agencies

•Referrals for follow-up appointments•Referrals to DME suppliers •Referrals to community resources•Information given to post-hospital care providers

•Information about local resource providers

Appealing a Hospital Discharge

Hospital discharge appeals

• Starting a hospital discharge appeal is the same for Original Medicare as it is for a Medicare Advantage plan

• If beneficiaries or their caregivers think they are being asked to leave the hospital too soon, they should follow the instructions to appeal the hospital discharge decision

Hospital discharge appeals • Instructions are on the notice a beneficiary receives before discharge,

titled Important Message from Medicare:o The appeal must be filed by midnight on the date of discharge

Medicare will pay for the beneficiary’s hospital care while their first level of appeal is decided

o The BFCC-QIO should provide a decision within 24 hours of the filing of the appeal

o If the BFCC-QIO decides against the beneficiary, beneficiary can take their appeal to the next level Medicare will only pay for the beneficiary’s hospital care at higher levels

of appeal if their appeal is successful– Beneficiary be charged by the hospital for the days they spent in the hospital after

their first appeal decision if further appeals are unsuccessful

• The upper levels of appeal are slightly different for Original Medicare and Medicare Advantage Plans

BFCC-QIO • Beneficiary and Family-Care Centered Quality

Improvement Organization (BFCC-QIO), the entity with which inpatient discharge appeals are filed

KEPRO– https://www.keproqio.com/

Livanta – http://bfccqioarea1.com/

• BFCC-QIOs are also responsible for quality control for hospital inpatients and outpatients o Any beneficiary who has received substandard hospital care

can lodge a quality of care complaint with the QIO

Important Message from Medicare

Medicare Coverage Post-Discharge

Coordination of care by primary care providers

• In the past, Original Medicare has only paid for post-hospital physician office visits and not for administrative tasks to manage a person’s care after they leave the hospital

• Now, Medicare pays primary care providers (PCPs) to manage a person’s care at home in the first 30 days after they leave a SNF, hospital, or partial hospitalization program The new benefit includes a face-to-face visit with the PCP and non-face-

to-face communications with the PCP’s office to coordinate care

• This benefit is covered under Medicare Part B Medicare pays 80 percent of a set fee for all care coordination

Beneficiary pays 20 percent of the Medicare-approved amount

Drug coverage after discharge• Prescriptions and drug administration can change when people

move to different settings for care

• These changes must be reconciled, and Part D plans are supposed to make it simpler for beneficiaries to access medicationso Part D plans must cover prescription drug refills before someone

is discharged from a hospital or SNF

o Part D plans cannot restrict refills when a person is first admitted to a nursing home or when a doctor prescribes a dosage change

o Part D plans must provide a temporary supply of non-formulary medications to nursing home residents

o Some Part D plans may provide a temporary non-covered drug supply to beneficiaries when they change care settings

Skilled Nursing Facility (SNF) care• Part A covers:

o Semi-private room and mealso Skilled nursing care and/or therapyo Medicationso Medical supplies and equipmento Medical social services and dietary

counselingo Ambulance transportation, when

necessary

Skilled Nursing Facility (SNF) care

• Part A coverage applies if all of the following are true: o The patient has been a hospital inpatient for 3+ consecutive

days before their SNF stayo The patient entered a Medicare-certified SNF within 30

days of leaving the hospitalo The patient needs skilled nursing care 7 days/week or

therapy at least 5 days/weeko The patient uses a Medicare-certified SNF

Home health care

• Part A and/or Part B covers: o Skilled nursing care and skilled

therapy serviceso Home health aide services

(personal care)o Medical social serviceso Medical supplieso DME (covered separately by Part

B)

Home health care

• Part A and/or Part B coverage applies if all of the following are true:o The patient is considered homeboundo The patient needs skilled nursing services and/or therapyo The patient has an office visit with a health care

professional within 90 days of beginning to receive home care or 30 days after care begins The patient’s doctor regularly reviews a plan of home

health careo They patient receives care from a Medicare-certified home

health agency

SNF and Home Health Skilled Care Requirements

Skilled nursing

• Care that needs to be given by a registered nurse (RN) or licensed practical nurse (LPN) including:• Intravenous injections• Tube feeding• Catheter changes• Changing sterile dressings

on a wound

Skilled therapy

• Services that can only be performed safely and correctly by a licensed therapist, and that are reasonable and necessary for treating an illness or injury. These include:• Physical therapy• Speech-language pathology• Occupational therapy

OR

Resources for Today’s Webinar• Available for download in the pre and post webinar

emails from WebEx

• Also available for download at www.shiptacenter.org

> Login > Center Services > Events > Event Archives

Note: You must have a SHIP Staff account to download from the password-protected “Event Archives”

Questions?

The production of this webinar was supported by Grant No. 90ST1001 from the Administration for Community Living (ACL). Its contents are solely the responsibility

of the SHIP TA Center and do not necessarily represent the official views of ACL.

Email post-webinar questions about appeals to:

medicarehelp@shiptacenter.org

Contact Info

Host: Ginny Paulson, SHIP TA Center:• gpaulson@shiptacenter.org • 877-839-2675 or 319-358-9402

Speaker: Kat Fitzpatrick, SHIP TA Center:•medicarehelp@shiptacenter.org•kfitzpatrick@shiptacenter.org •212-204-6234