CMS-R-193 Comment # 9

CMS, Office of Strategic Operations and Regulatory Affairs
Division of Regulations - C
Attention: Bonnie L. Harkless
Room C4-26-05
7500 Security Blvd.
Baltimore, Maryland 2 1244-1850
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C o q e n t s : Revised Version - Important Message from Medicare (CMS-R-193)
The following comments address the necessity and utility of the proposed information collection and the
accuracy of the estimated burden on hospitals, pertaining to Revised Version of the Important Message
from Medicare, as requested in a notice published in the January 5,2007 issue of the Federal Register:
Medicare inpatients currently receive a copy of the Important Message from Medicare on admission.
Requiring a signature from patient or family on the revised IM is a throwback to the 1980's, when the
IM required a signature. This requirement was dropped in the 1990's, due to the excessive amount of
time hospitals spent meeting that requirement for a variety of reasons -patient too ill, too painful,
sedated, asleep, no family member present in room, etc. The majority of inpatients are admitted
directly to the nursing units from the Emergency Dept., doctor's office, or home. The only scheduled
inpatient admissions are generally for surgery or interventional procedures.

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Coordinating the hand-off from the delivery of the initial IM from Patient Registration to Case
Management for delivery of the IM copy will be an operational nightmare. Estimating discharge date
POdays in advance is particularly difficult, since most physicians cannot predict in advance that a
patient will be stable enough for discharge. Often they do not know a patient will be ready for
discharge until test results are available.
There is confusion as to how to handle situations where the primary insurance is a commercial carrier
with Medicare as a secondary payor, when Medicaid is the secondary payor, or when the
physicianfUR Committee changes an inpatient to observation status, per condition code 44, prior to
discharge.
Since there was no CMS pilot conducted, we question the accuracy of the time estimates to cany out
the provisions of this rule. Three minutes per second IM copy to be delivered seems unreasonably
low, considering it will take more than three minutes per case to decide who is to receive the copy.
Estimating that only 1% of inpatients will exercise their right to appeal pending discharge, based on
the number of HlNN's (Hospital Issued Notice of Non-Coverage) currently issued, is an exceedingly
small percentage. Most hospitals have curtailed use of the HlNN for continued stay, because it allows
the patient 72 hours before assuming financial liability. Rather than serve a notice, Discharge
Coordinators try to work with the patients and families to move them expeditiously to the next
appropriate lower level of care.
CMS should consider delaying implementation until a hospital pilot is conducted to determine
feasibility of projections and financial impact on hospital operations. This regulation will consume
pore hospital and QIO resources, increase length of stay, and will add one more thing to the rising
cost of healthcare.

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