CMS-R-193 Comments # 11 thru 16

b.

MCHC

Metropolitan
Chicago
Healthcare Council

222 South Riverside Plaza
Chicago, Illinois 60606-6010
Telephone 312-90&6000
Facsimile 312-993-0779

http://www.mchc.org
February 27,2006
Centers for Medicare and Medicaid Services
Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development
Attn: Bonnie L. Harkless
CMS-R-193, Room C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850
RE:

Document Identifier: CMS-R-193
Agency Information Collection Activities: Proposed Collection; Comment
Request
Published in the Federal Register of January 5, 2007 (72 FR 568-569)

I am writing on behalf of the Metropolitan Chicago Healthcare Council, which represents 140
healthcare entities, including more than 100 Illinois hospitals, the majority of which are
located in the eight-county metropolitan Chicago area. We appreciate the opportunity to
provide comments on the above referenced proposed collection of information through a
revised "The lmportant Message from Medicare" (OMB 0938-0692), which is used by
hospitals to notify Medicare beneficiaries of their inpatient discharge appeal rights.
New regulations set forth in the final rule CMS-4105-F require hospitals to secure an
appropriate signature on "The lmportant Message from Medicare" from every Medicare
patient receiving inpatient services, including those enrolled in a Medicare Advantage
managed care plan, within two days of admission. The hospital is also required to give a
follow-up copy of the signed "lmportant Messagento the beneficiary within two calendar
days before discharge. We recommend that CMS consider our suggestions for improving
the "lmportant Message," the full cost of compliance, and a number of other issues in
finalizing this form and the discharge notification process.
Ways to enhance the quality, utility, and clarity of the information to be collected
We have several suggestions for improving the revised "lmportant Message:"
On page 2, the second bullet point erroneously refers to the QIO being available 24
hours a day. In Illinois, the beneficiary helpline at the QIO is currently staffed 8:00
a.m. to 4:30 p.m., Monday through Friday. CMS will need to articulate any special
instructions that apply to evenings, weekends, and holidays so that the beneficiary is

familiar with applicable timeframes and knows what to expect. It would also be
helpful to clarify that the beneficiary should contact the QIO whether they are
enrolled in the original Medicare program or have elected a Medicare managed care
product.
The instructions for completion of the notice indicate that the hospital is to insert the
name and telephone number of the Medicare Advantage plan on page 2 if the
patient is an enrollee in such a plan; however, there is no designated place on page
2 to do this. We would suggest, however, that hospitals not be required to provide
this information on the form. Beneficiaries enrolled in managed care plans frequently
present their Medicare cards upon admission, and the hospital does not discover
until later that the patient is in a Medicare Advantage plan. As a result, the hospital
may not know at the time of admission that the beneficiary is not enrolled in the
original Medicare program. If CMS believes the contact information for the health
plans must be provided to beneficiaries, we recommend that CMS be responsible for
creating and updating a list of plan names and telephone numbers and making it
available to hospitals, rather than requiring individual hospitals to do this.
The "lmportant Messagencurrently includes a single space for the date that the
beneficiary or representative initially signed the form. We suggest that additional
space be added for hospitals to record the dates that copies of the form are given to
the patient.
We would like to see more direct language that if the patient does not appeal the
physician's discharge decision and elects to remain in the hospital, the beneficiary
will be responsible for payment.
Accuracy of the estimated burden
CMS estimates that the revised regulations will increase the time for hospitals to deliver the
"lmportant Message" from an estimated one minute per beneficiary to 13.8 minutes on
average for the delivery of the two notices, with 13 million beneficiaries receiving the initial
notice and 60 percent of beneficiaries with inpatient stays of more than three days (or 7.8
million) also receiving a copy of the signed notice closer to discharge. CMS indicates in the
final rule CMS-4105-F that it will take the hospital an average of 12 minutes to deliver the
initial revised "lmportant Message" and obtain a signature, and that the follow-up delivery of
a copy of the notice will take an average of three minutes per patient.
We believe that CMS has underestimated the length of time it will take the hospital to deliver
the second notice to the beneficiary. We can only assume that CMS arrived at three
minutes per patient by envisioning a process that requires staff working near the patient's
room to remove a copy of the signed "lmportant Message" from the patient's chart and
hand-deliver it to the patient without any explanation whatsoever.
What has not been taken into consideration is the time to explain the form again to the
beneficiary or the beneficiary's representative, to locate the beneficiary's representative if
the beneficiary is not able to understand the form, or to secure any necessary translator
services. It also does not account for the fact that hospitals may designate staff in
departments not physically located by the patients' rooms (e.g., discharge planning, social
work, patient representatives) to deliver the notice. Finally, the estimate does not consider

V

situations where multiple copies of the "Important Message" will need to be delivered to the
patient if a discharge occurs later than initially expected for whatever reason. CMS will need
to clarify its expectations for delivery of the copy and to better take into account how this
delivery occurs.
Additional Issues
As CMS develops a Medicare transmittal to communicate its administrative instructions on
implementation of the revised "lmportant Message," we ask that the following issues be
addressed:
Do the procedures apply to beneficiaries with Medicare Part B only benefits?
Who meets the definition of the patient's representative? We suggest that a liberal
definition be adopted.
What are the specific communication and documentation procedures CMS expects
hospitals to follow when delivering the proposed discharge notices to a beneficiary's
family who does not reside locally?
How is the QIO staffed for these changes? Will the QlOs be provided enhanced
funding for additional staffing so appropriate access and services are available seven
days a week?
What information will CMS develop for hospitals to share with physicians to educate
them about this new process?
Further Information
Thank you again for the opportunity to review CMS' proposed changes to the "lmportant
Message" and to offer comments. If you have any questions about the issues raised above
or you need any additional information, please feel free to contact me at 3121906-6007,
email [email protected].
Sincerely,

Susan W. Melczer
Director, Patient Financial Services

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Attention: Bonnie L Harkless
CMS Office of Strategic Operations and Regu atory Affairs
Division of Regulations - C
Room C4-26-05
7500 Security Blvd
Baltimore, MD 2 1244-1850
Heather Freiheit, RN, BSN
Clincal Manager, Emergency Services
Rogue Valley Medical Center
2825 E Barnett Road
Medford OR 97504-8332

Comments: Revised Version - Important Message from Medicare (CMS-R- 193)
I am writing this letter to express my concern with the plan to initiate a second
distribution of the Important Message From Medicare (IM). Currently patients receive the IM at
their initial entry into the hospital and confirm acceptance via a signature. If the mandate is
enacted to give patients a second copy of the IM two days prior to discharge; I believe not only
will this be an operational nightmare for the hospitals to implement there will also be a high
incidence of failure and non-compliance.
This failure will not come from lack of trying but the inability of case managers,
discharge planners, etc. to accurately know 48 hours prior to a physician's plan to discharge the
patient. Frequently, the physician's decision to discharge the patient is a result of a final test or,study result. In addition, with the increased use of Hospitalists, a different doctor may be the
attending physician for the patient each day. As it is, currently just obtaining an estimated
discharge date form the doctors is challenging enough for long-term placement and Home Health
follow-up. With the confusion around how to give and who will need to receive the IM, if the
patient also has a commercial or secondary payor it doesn't seem realistic to assume redelivering the 2ndIM will only take 3 minutes. Frequently, patients will be too ill, tired, or
medicated to receive the form and there may not be any family present to take the IM.
Although I can appreciate the initial vision of the 2ndIM, since only a small percentage of
in-patients exercise their right to appeal. It seems as if hospitals would make better use of their
staffs time and valuable resources to work on patient placement or discharge to facilitate
hospital room turnover and decrease the length of stay.
I am urging CMS to re-evaluate the feasibility of this plan and asking you to please reevaluate if a second IM is really necessary or will it be a financial strain and labor intensive for
hospitals who are already struggling with finding qualified staff and trying to be fiscally
responsible.
,

Thapk you,

ROGUEVALLEY
MEDICAL
CENTER

_P

FRANKLIN MEMORIAL HOSPITAL
A Caritlg Hosp/ta!fi)rr / Hctrltl?~'Cbttrttrwl//~'

CMS, Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development - C
Attention: Bonnie L. Harkless
Room C4-26-05
7500 Security Blvd.
Baltimore, Maryland 2 1244-1850
To Whom It May Concern:
This is a response to CMS-R-193, your proposal of issuance of an additional Important Message from Medicare at
an acute care facility.
We fail to see the purpose or advantage of this practice. Medicare already has a denial process in place for
inpatient stay. This process (Hospital Issued Notices of Non-coverage) covers all possible instances, i.e.
admission, continued stay and/or refusal of a skilled bed. They include notification and review by your QIOs to
protect the recipients and insure correct Medicare utilization. What you propose is redundant.
'

Our average length of stay is 3.6 days. Therefore, we would have to issue the notice at admission or the next day.
When a patient is acutely ill, the stress and anxiety of the illness or procedure should not be compounded by what is
perdeived as a threat of (non-payment) financial responsibility for their stay. No matter how eloquent the
explanation, experience shows that "hearing" stops with the word "denial" or "if you stay in the hospital after your
planned date of discharge, it is llkely that your charges for additional days in the hospital will not be covered by
Medicare or your Plan." T h ~ type
s
of anxiety can prolong the illness or encourage the patient to leave before they
are medically stable.
The government has the QIO, C-DAK, PEPPER, JCAHO, the Fiscal Intermediary, and state licensing and
regulatory agencies monitoring hospital's acute care management and patient outcomes as well as Medicare's fiscal
utilization. In this day and age of sky rocketing health care costs, it is irresponsible to require a redundant program
that requires an increase use of resources and personnel to manage. It will inevitably cause delays in discharge,
which again will increase health care costs.

C

irs & Education

111 Franklin Health Commons Farnli~lgton,ME 04938
Tel: 207-778-6031 ME 800-398-6031 TTY 207-779-2662 FA\: 207-779-2548 \cwfchn.org
An Afnliate of Franklin Community Health Network

Page 1 of 1

Harkless, Bonnie (CMSIOSORA)
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From:

Malarnud, Matthew [[email protected]]

Sent:

Tuesday, March 06, 2007 10:07 AM

To:

Harkless, Bonnie (CMSIOSORA)
RE: Important Message from Medicareuse: Requirements that hospita Is notify beneficiaries in inpatient
hospital settings of their rights as a hospital patient...

Subject:

V

Attachments: Important Message Revision Comment Letter 030607.pdf
Dear Ms. Harkless:
The AHA appreciates the opportunity to comment on the information request published in the Federal Register (Vol. 72, No. 3) on
Friday, January 5, 2007. Attached as a pdf are our comments. Thank you.
Sincerely,
Matthew M. Malamud
Executive Assistant, Policy
American Hospital Association
325 Seventh Street, NW, STE 700
Washington, DC 20004
202.626.3754
202.626.4626 Fax
[email protected]
www.aha.org

American Hospital
Association
March 6, 2007
Leslie Norwalk
Acting Administrator
Centers for Medicare & Medicaid Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W., Room 445-G
Washington, DC 2020 1
Re: CMS Proposed Revision of Important Message from Medicare and Related Paperwork
Requirements (Vol. 72, No. 3), January 5,2007

Dear Ms. Norwalk:
The American Hospital Association (AHA), on behalf of our nearly 5,000 member hospitals, health
systems and other health care organizations, and our 37,000 individual members, appreciates this
opportunity to comment on the Centers for Medicare & Medicaid Services' (CMS) proposed revision
of the "Important Message from Medicare" (IM) and its related paperwork requirements as submitted
to the Office of Management and Budget. This revision seeks to implement the revised regulations
on notification of Medicare beneficiaries regarding their hospital discharge appeal rights, which were
published on November 27, 2006 in the Federal Register.
AHA appreciates the extent to which CMS responded to many of the practical problems identified in
our comments on the proposed rule. While the final regulation is much more workable, it still
represents a significant increase in burden on hospitals. Our comments on the proposed notice
package now focus on how to minimize that burden, where possible, and resolve open questions
regarding the notice and appeal process.

MINIMIZING
ADMINISTRATIVE
BURDEN
FOR HOSPITALS
Currently, hospitals provide the IM to beneficiaries when they are admitted to the hospital, generally
in the patient's admission package. The IM explains a beneficiary's right to have their discharge
decision reviewed by the local Quality Improvement Organization (QIO) if they believe they are
being discharged too soon. The notice provides all the information needed by a beneficiary to
request such an appeal and explains that they will not be held financially liable for continued hospital
care while the QIO reviews their case. A more detailed notice with specific reasons why hospital
care is no longer required is provided when beneficiaries indicate that they are not comfortable with
the planned discharge date.

Leslie Norwalk
March 6,2007
Page 2 of 3
Under the new regulations, which take effect on July 1, the IM will be provided to beneficiaries no
later than two days following admission, but hospital staff must ensure that the beneficiary
understands the notice and signs a copy of it documenting when he or she received it and that they
understand it. A copy of the signed notice will be given to him or her at that time. The hospital must
then provide another copy of the signed notice no more than two days prior to discharge. Detailed
information about a particular discharge will be required only when a beneficiary requests a QIO
review. We believe that focusing the process and beneficiary questions on the front-end of the
admission will help form more realistic beneficiary expectations about hospital admissions and
improve their understanding of how decisions are made and how the discharge planning process
works. However, it comes at a heavy price.
Even with the conservative burden estimate included in the paperwork clearance package, CMS
projects that the burden will increase from 208,333 hours to 2,990,000 hours - a more than fourteenfold increase. And, while the former notice was provided by admissions clerks, the new process
requires someone with the ability to explain medical necessity and the discharge planning process generally a nurse case manager or social worker - to present the paperwork. The national average
hourly wage for clerks is about $12.50, while the average hourly wage for nurses and social workers
is about $24.00 - $28.00. Conservatively, that takes the cost from about $2.6 million to between
$71.8 and $83.7 million.
Even though it might require some minor adjustments to the final rule, AHA urges CMS to take the
following actions to minimize the administrative burden of this new notice andprocess:
Eliminate the requirement that the repeat notice at discharge be a copy of the notice signed
at admission. Since beneficiaries would receive a copy of the signed notice when they sign
it, it would be simpler and less burdensome to allow hospitals to provide just the generic
notice language at discharge. We have heard from some hospitals that it would be
significantly more efficient to simply print the notice as part of their discharge instruction
package.
Afer thefirst year of implementing this newprocess, perform an evaluation of whether the
newprocess has yielded sufficient benefit to warrant this significant increase in
administrative costs. Too often, administrative requirements are adopted to address
anticipated or perceived problems. That has already happened once with this requirement. It
was adopted by statute when the inpatient prospective payment system was enacted and there
were widespread fears of "quicker, sicker" discharges. Those fears were not realized. There
also was an earlier requirement for beneficiaries to sign for receipt of the notice; that too was
found to be unnecessary and subsequently eliminated.
Provide significant latitude to hospitals in how they provide the notice to beneficiaty
representatives ifthe beneficiary is unable to receive or understand the notice. This issue
was raised during comment on the proposed rule, and the preamble discussion of the final
rule indicated that CMS planned to provide guidance regarding how hospitals and health
plans may deliver the appropriate notice in cases where a beneficiary's representative may
not be immediately available. Such guidance was not included in the instructions for the
notice. We urge CMS to allow hospitals to use any means of communication (telephone, fax,
email, etc.) necessary to conduct the notice process with beneficiary representatives and
allow record notations when these alternatives to in-person notice are used.

Leslie Norwalk
March 6,2007
Page 3 of 3
Provide on CMS' Web site the text of the notice translated into the top 15 languages
hospitalsfrequently encounter. Almost one-fifth of the U.S. population speaks a language
other than English at home. Hospitals are required to provide language services for such
individuals, but they do not receive compensation for the cost of those services. The size of
this population and the vast number of languages now being encountered make it very
difficult for individual hospitals to provide translated documents. Since the text of this notice
cannot be altered by the hospital, CMS should obtain and provide translations of the key
beneficiary notices. The Social Security Administration has a list of 15 languages that it uses
for such purposes. Last year, the AHA'S research affiliate, the Health Research and
Educational Trust, conducted a survey of hospital language services which found 15
languages that at least 20 percent of hospitals encounter frequently. They are: Spanish;
Chinese; Vietnamese; Japanese; Korean; Russian; German; French; Arabic; Italian; Laotian;
Hindi; Polish; Tagalog; and Thai.

NEEDED CLARIFICATIONS
There are several clarifications that would be helpful in the notice and instructions.
ClarijPy on thefirstpage of the notice that beneficiaries have the right to receive "medicallv
necessary" hospital services covered by Medicare. Beneficiaries need to understand that the
standard is medical necessity, not what they think is needed.
Issue instructions to the QIOs regarding their required availability 24/7 to deal with
beneficiary appeals. The current QIO manual indicates that QIOs are not required to be
available 24 hours a day, only during normal business hours. They are required to have an
answering machine to take messages, but they are not required to pick up or return messages
until the next business day. Page 2 of the notice is inconsistent with the QIO manual.
Reconcile the notice form and the instructionsfor completing the notice for Medicare
Advantageplan enrollees. Hospitals are told to fill in the name and telephone number of the
Medicare Advantage plan for enrolled beneficiaries, but there is no place on the form to do
SO.

If you have questions about our comments, please contact me or Ellen Pryga, AHA director for
policy, at (202) 626-2267 or elx) c:-l:tiaha.org.
Sincerely,

Rick Pollack
Executive Vice President
cc: Bonnie L. Harkless

Memorandum
To: CMS, Ofice of Strategic Operations and Regulatory Affairs,
Division of Regulations Development - C
Attention: Bonnie L. Harkless
Room C4-26-05,
7500 Security Blvd.
Baltimore, Maryland 2 1244-1850
Jackie Birmingham,n\.

af5. ( MA<

Vlce Presdent, Profess~onalServices

From: Jackie Birmingham, RN, MS, CMAC
VP ~rofessioni~
Services
Curaspan, Inc./ the eDischarge Company
70 Bridge Street, Suite 201
Newton, MA 02458
j bi~~min~I~an_l@ci~rasp~n~~~o_~
CT ofice: (860)668-7575
Other: (78 1)492-80 13

70 Bridgc Strcct
Su~te201

OFI-ICF. 860.668.7575
MOBII.E 781.492.8013

860,668.6666

t~~

Date: March 2, 2007
Re: Comment on a Revised Version of the Im~ortantMessage from Medicare
"Important Message fiom Medicare (1M)(CMS-R-193)
Dear Ms. Harkless,
As a health professional working in the acute care setting, and in particular discharge planning

services, I support the initiative to inform Medicare Beneficiaries of their rights to participate in their
discharge plan and their right to appeal their discharge. Currently I am working for a company that
provides discharge planning software that is a web-based work flow tool that connects hospitals with
post-acute providers to facilitate the discharge planning process. Because of this I am acutely aware of
the challenges facing hospitals and Medicare beneficiaries.
I have reviewed the proposed IM and wish to recommend some changes in the working and sequence
of information. As an aside to this letter, I wanted to let you know that I am a member an organization
that is also submitting comments (The American Case Management Association). I wanted to also
make comments as an individual and as a Medicare Beneficiary. For your convenience, I have
enclosed three documents. The first is the proposed IM (yellow) , the second is the proposed IM with
recommended changes, and the third (pink) is the way the IM would look if all of the recommended
changes are accepted.
I look forward to tracking this very important project.

/

u

Ofh~\xha,ao7

OMB Approval No. 0938-0692

AN IMPORTANT MESSAGE FROM MEDICARE
(Please Read Carefully)
Patient Name
Attending Physician

Patient ID Number
Date of Notice

YOUR RIGHTS AS A HOSPITAL PATIENT
You have the right to receive necessary hospital services covered by Medicare or covered
by your Medicare Health Plan (your "Plann)if applicable..
You have the right to be involved in any decisions that the hospital, your doctor, your Plan
or anyone else makes about your hospital stay.
You have the right to receive services you need after you leave the hospital (that is, after
you are "dischargedn).
You have a right to know about these services, and the have freedom to choose where
you will get services.
You will be offered a choice between appropriate and available agencies or services
ordered by your physician.
Medicare or your Plan may cover some of these services if ordered by your doctor

YOUR HOSPITAL DISCHARGE AND MEDICARE APPEAL RIGHTS
Planning For Your Discharge: During your hospital stay, the hospital staff will be working
with you and your doctor (and your Plan, if applicable) to plan for your discharge and arrange
for services you may need after you leave the hospital. When your doctor decides you no
longer need hospital care and can safely receive care in another setting, you will be informed
of a discharge date
If you think you are being discharged too soon:
Talk to the hospital staff and your doctor (and your Plan, if applicable) about your concerns.
If you are not satisfied with the discharge plan, you have the right to request an appeal
The appeal process involves an independent review from the Quality Improvement
Organization (QIO) in your area.
If you are concerned about your discharge you should contact the QIO as soon as
possible after you are informed of your discharge date, but before you leave the hospital
Staff at the QIO will give you and your doctor a second opinion about whether you are
ready to leave the hospital.
If you appeal your discharge by your discharge date, your hospital services will continue to
be paid by Medicare, or your health plan, during the appeal process.
Page 2 outlines the appeal process and how to contact your QIO.

Please sign below to show that you have received this notice and understand it.
Signature of Patient or Representative

Date

CMS-R-193

(Revision Date)

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PAGE 2: HOW TO ASK FOR AN IMMEDIATE APPEAL OF YOUR DISCHARGE
If you want to request an appeal about your discharge, you should contact the Quality
Improvement Organization (QIO) as soon as possible after you are informed of your
discharge date, but before you leave the hospital.
If you request an appeal by your discharge date, your hospital services will continue
to be paid during the QIO review until at least noon of the day after the QIO notifies
you of its decision.
Here is the contact information for the QIO:
{insert name and nurr~berof
the QlOl
The QIO accepts requests for appeals 24 hours a day. You may also call the QIO if you
have questions about the appeal process.
If you request an appeal, you and the QIO will both receive an explanation from your doctor
and the hospital staff, if applicable, that explains the reasons that your doctor determined
that you are ready to be discharged.
The QIO will ask for your concerns related to your discharge, and review the information
about your medical condition provided by your doctor and the hospital. . You do not have
to prepare anything in writing, but you or your representative have the right to give the QIO
a written statement or any information you wish. You or your representative should be
available to speak with the QIO.
The QIO will notify you of its decision within one day after it receives all necessary
information.

o If the QIO agrees that you are not ready to be discharged, Medicare will continue to
cover your hospital services that are medically necessary.
o If the QIO finds you are ready to be discharged you will be responsible for payment
of your hospital services beginning at noon of the day after the QIO notifies you of
its decision until you are discharged.
YOU ALSO HAVE APPEAL RIGHTS AFTER YOU HAVE BEEN DISCHARGED:
If you have Original Medicare:
o If you were notified of your date of discharge and disagreed with the date, but did not
appeal before you were discharged, you may still ask the QIO to review your
hospital stay.
The hospital can charge you immediately for services you received after your
planned date of discharge.
o If the QIO decides your Medicare coverage should have continued after you have
made payments, you will receive a refund.
o A bill for your hospital services will be submitted to Medicare by the hospital.
o You will receive a Medicare Summary Notice (MSN) regarding the decision
on your appeal and your right to appeal that decision.
If you belong to a Medicare Health Plan:
o If you do not request an appeal by your discharge date, you may still ask the QIO
for a review of your hospital stay. However, if your health plan decides discharging
you was the appropriate decision, you may be responsible to pay for any hospital
services you receive after your discharge date from the hospital.
Consult your Medicare Handbook or call 1-800-MEDICARE (1-8004333-4227), or l T Y : 1-877486-2048 for more information about this notice and the Medicare claims appeal process.
Accordin to the P w o r k Redudion Ad of 1995, no persons are required to r e s p d to a collection of information unless it displays a valid OMB control
number. h e v a l i d a 8 ~control
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number forathisinformation colledon is 093% 0692. Ibe time required to complete this information collection is
estimated to average 13.8 minutes per response,including the time to review instructions, search existing data resources, gather the data needed, and
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OMB Approval No. 09380692

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AN IMPORTANT MESSAGE FROM MEDICARE
(Please Read Carefully)
Patient Name

Patient ID Number

Attending Physician

Date of Notice

YOUR RIGHTS AS A HOSPITAL PATIENT

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You have the right to receive necessary hospital services covered by Medicare~covered
by your Medicare Healh Plan (your 'Plan") ~fappllcabe,

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You have the right to be involved in any decisions that the hospital, your doctor, your Plan
or anyone else makes about your hospital stay.
You have the right to receive services you need after you leave the hospital (that is, after
you are 'discharged").
You have a rlqht to know about these serv~ces,and the have freedom to choose where
you wlll qet sew~ces
You w11lbe offered a cholce between approprrate and avsriabie aqencres or s e w ~ c e s

I Dolate& or your Ran. You have a

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with you and your doctor (and your Plan, if applicable) to plan for your discharge and arrange
for services you may need after you leave the hospital. When your dodorgecides you no
longer need hospital c a r e m c a n safely receive care in another setting, you will be informed
of &discharge date,

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covered during the appeal.

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Talk to the hospital staff and your doctor (and your Plan, if applicable) about your concerns.

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If you are not satlsfled wlth the dlscharqe plan you,have the rigM to request an appeal.
.The appeal process lnvolvesan independent review,from the Quality Improvement
Organization ( Q 1 O ) j your area
If you are concerned about your dlscharqe you should contact the QIO as soon as
poss~bleafter vou are tnforrned of your dlscharqe date, but before you leave the hosp~tal
Staff at the QIO will give you and your doctor a second opinion about whether you are

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You should contact your QIOas soon
as possible afier you are informedof
your discharge date, but before you
leave the hospital.-

ready to leave the hospital..

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your discharge date, your hospbl
s e ~ c e will
s continue to be paid
during the appeal (exceptfor charges
like your coinsurance and
dedudibles) until noon of the day
afterthe QIOnotihes you of its
decisi0n.W

Page 2putl1nes_theappeal process and how to contact your QIO.

Please sign below to show that you have received this notice and understand it.
Date

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If you appeal your discharqe by vour dlscharqe date, your hosp~talservices wlll continue to
be pald by Medicare or your health plan, durlnq the appeal process,,

Signature of Patient or Representative

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CMS-R-193

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TO ASK FOR AN IMMEDIATE APPEAL OF YOUR DISCHARGE

If you want to request an appealaout vour dlschar~e,you should contact .the-Quality
lmprovemerrt Organization (QIO) as soon as possible after you are informed of your
discharge date, but before you leave the hospital.
If you request an appeal by your discharge date, your hospital services will continue
to be paid during the Q10 review until at least noon of the day after the Q10 notifies
you of its decision.
Here is the contact information for the QIO:
{insert name and number of
the QIO)
-The QIO accepts requests for appeals 24 hours a day. You may also call the QIO if you
have questions about the appeal process.
Jf you request an appeal. you and the QIO will both receive 2 n expianat~onfrom your doctor
and the hospital staff, if applicable that explains the reasons that your doctor,,determ~ned
W y o u are ready to be discharged.
.The QIO will ask for your Foncerns related to your dlscharqe. and revlew the informatlon
about your medlcal condit~onprovtded by your doctor and the hosp~tal, You do not have
to prepare anything in writing, but you or your representative have the right to give the QIO
a written statement or any information you wish. You or your representative should be
available to speak with the QIO.
,The QIO will notify you of its decision within one day after it receives aH necessary
information.
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YOU ALSO HAVEAPPEAL RIGHTS AFTER YOU HAVE BEEN DISCHARGED:
If you have Original Medicare:
o If you were notfled of your date of d~scharqeand d~saclreedw ~ t hthe date but dld not
a w e a t before you were d~scharqed,you may still ask the QIO to review your
Jospltal stay.

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planned date of discharge.
c - If the QIO decides your Medicare coverage should -continued
after you have
made payments, you will receive a refund
o A m f o r your hospital services will be submitted to Medicare by the hospital.
o You will jecelve a Medicare Summary Notice (MSN) regardingmecision
on your appeal and vourjight to appeal that decision.
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Consult your Medicare Handbook or call 1800-MEDICARE (1-800-633-4227), or TTY: 1-877486-2048 for more information about this notice and the Medicare claims appeal process.

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OM0 Approval No. 0938-0692

AN IMPORTANT MESSAGE FROM MEDICARE
(Please Read Carefully)
Patient Name
Attending Physician

Patient ID Number
Date of Notice

YOUR RIGHTS AS A HOSPITAL PATIENT
You have the right to receive necessary hospital services covered by Medicare or covered
by your Medicare Health Plan (your "Plan") if applicable..
You have the right to be involved in any decisions that the hospital, your doctor, your Plan
or anyone else makes about your hospital stay.
You have the right to receive services you need after you leave the hospital (that is, after
you are "discharged").
You have a right to know about these services, and the have freedom to choose where
you will get services.
You will be offered a choice between appropriate and available agencies or services
ordered by your physician.
Medicare or your Plan may cover some of these services if ordered by your doctor
YOUR HOSPITAL DISCHARGE AND MEDICARE APPEAL RIGHTS
Planning For Your Discharge: During your hospital stay, the hospital staff will be working
with you and your doctor (and your Plan, if applicable) to plan for your discharge and arrange
for services you may need after you leave the hospital. When your doctor decides you no
longer need hospital care and can safely receive care in another setting, you will be informed
of a discharge date
If you think you are being discharged too soon:
Talk to the hospital staff and your doctor (and your Plan, if applicable) about your concerns.
If you are not satisfied with the discharge plan, you have the right to request an appeal
The appeal process involves an independent review from the Quality Improvement
Organization (QIO) in your area.
If you are concerned about your discharge you should contact the QIO as soon as
possible after you are informed of your discharge date, but before you leave the hospital
Staff at the QIO will give you and your doctor a second opinion about whether you are
ready to leave the hospital.
If you appeal your discharge by your discharge date, your hospital services will continue to
be paid by Medicare, or your health plan, during the appeal process.
Page 2 outlines the appeal process and how to contact your QIO.
Please sign below to show that you have received this notice and understand it.
Signature of Patient or Representative

Date

(Revision Date)

CMS-R-193

If you want to request an appeal about your discharge, you should contact the Quality
Improvement Organization (QIO) as soon as possible after you are informed of your
discharge date, but before you leave the hospital.
If you request an appeal by your discharge date, your hospital services
will continue
to be paid during the QIO review until at least noon of the day after the QIO notifies
you of its decision.
Here is the contact information for the QIO:
{insert name and number of
the QIO]
The QIO accepts requests for appeals 24 hours a day. You may also call the QIO if you
have questions about the appeal process.
If you request an appeal, you and the QIO will both receive an explanation from your doctor
and the hospital staff, if applicable, that explains the reasons that your doctor determined
that you are ready to be discharged.
The QIO will ask for your concerns related to your discharge, and review the information
about your medical condition provided by your doctor and the hospital. . You do not have
to prepare anything in writing, but you or your representative have the right to give the QIO
a written statement or any information you wish. You or your representative should be
available to speak with the QIO.
The QIO will notify you of its decision within one day after it receives all necessary
information.

o If the QIO agrees that you are not ready to be discharged, Medicare will continue to
cover your hospital services that are medically necessary.
o If the QIO finds you are ready to be discharged you will be responsible for payment
of your hospital services beginning at noon of the day after the QIO notifies you of
its decision until you are discharged.
YOU ALSO HAVE APPEAL RIGHTS AFTER YOU HAVE BEEN DISCHARGED:
If you have Original Medicare:
o If you were notified of your date of discharge and disagreed with the date, but did not
appeal before you were discharged, you may still ask the QIO to review your
hospital stay.
The hospital can charge you immediately for services you received after your
planned date of discharge.
o If the QIO decides your Medicare coverage should have continued after you have
made payments, you will receive a refund.
o A bill for your hospital services will be submitted to Medicare by the hospital.
o You will receive a Medicare Summary Notice (MSN) regarding the decision
on your appeal and your right to appeal that decision.
If you belong to a Medicare Health Plan:
o If you do not request an appeal by your discharge date, you may still ask the QIO
for a review of your hospital stay. However, if your heatth plan decides discharging
you was the appropriate decision, you may be responsible to pay for any hospital
services you receive after your discharge date from the hospital.

Consult your Medicare Handbook or call 1-800-MED ICARE (1400433-4227), or lTY: 1477486-2048 for more information about this notice and the Medicare claims appeal process.
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PAGE 2: HOW TO ASK FOR AN IMMEDIATE APPEAL OF YOUR DISCHARGE

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Greater New York Hospital Association
555 West 57th Street I New York, N.Y. 10019 I (21 2) 246-7100 I FAX (212) 262-6350
Kenneth E. Raske, President

February
Twenty-Seven
2007
Centers for Medicare & Medicaid Services
Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development - C
Attention: Bonnie Harkless
Room C4-26-05
7500 Security Blvd.
Baltimore, Maryland 2 1244-1850

RE:

Agency Information Collection Activities: Proposed Collection; Comment Request
Document Identifier: CMS - R - 193
Important Message from Medicare
OMB #: 0938 - 0692

To Whom It May Concern:
Greater New York Hospital Association (GNYHA) represents more than 175 not-for-profit and
public hospitals in New York State, New Jersey, Connecticut, and Rhode Island. We welcome
the opportunity to comment on the Centers for Medicare & Medicaid Services (CMS) notice for
the proposed paperwork collection for document identifier CMS - R - 193.
CMS is seeking public comment on a revised version of the Important Message from Medicare
(IM) whereby beginning July 1, 2007, hospitals must deliver the IM to inform Medicare
beneficiaries who are hospital inpatients about their hospital discharge appeal rights. This notice
will be required for original Medicare beneficiaries and for those enrolled in Medicare health
plans.
We appreciate CMS's attempt to create an enhanced process for informing Medicare
beneficiaries of their discharge appeal rights; however, GNYHA does not believe that CMS
accurately calculated the burden estimate. In addition, GNYHA is submitting additional remarks
with respect to enhancing the quality, utility, and clarity of the information to be collected. Our
comments and recommendations are summarized as follows:
CMS has significantly underestimated the cost burden on providers by failing to consider
the additional expenses and work effort that providers will incur to: a) issue the follow up
IM to all Medicare beneficiaries; b) pursue signatures from the authorized representative
at admission and prior to discharge when the patient is not capable of comprehending the

IM; and c) develop and purchase specialized carbonless multi-page forms to demonstrate
compliance with this new Medicare regulation.
The revised IM is materially inaccurate with respect to the stated hours that the QIO is
available to accept and process discharge appeals. In addition, because of the timesensitive nature of requesting a discharge appeal, the IM should be revised to include a
brief explanation to make the Medicare beneficiary aware of potential financial liabilities.
The revised IM does not contain fields for annotating the health plan name and telephone
number as outlined in the draft instructions. For reasons that we outline later, GNYHA
believes this information requirement should be eliminated in any case since it will not be
materially useful to the Medicare beneficiary.
CMS should consider all reasonable alternative solutions so that hospital staff members
do not have to manually annotate the patient name, patient ID number, and physician
name on the IM.
CMS should accept mail, fax, and e-mail as acceptable alternatives for issuing the IM at
admission and in advance of discharge when the patient is not competent to understand
the IM and the authorized representative is not physically present to receive the notice.
Accuracy of the Estimated Burden

While we appreciate that CMS has attempted to lessen the burden on the provider and will not
require that the follow up IM be re-issued if the original delivery and signing of the IM took
place within 2 days of discharge, we believe that CMS has understated the cost burden.
Suggesting that hospitals implement a process that on an exception basis uses length of stay as a
proxy to decide which Medicare patients receive the follow-up IM, as a practical matter is not
dependable and could cause some patients to be unintentionally overlooked. It is likely that
hospitals will need to establish a uniform notification process for short- and long-stay admissions
so that every Medicare patient is included in the re-issuance of the copy of the signed IM, not
just patients with longer lengths of stay (i.e., > 3 days). Therefore CMS's estimate of the
financial burden is inaccurate in that it only calculates the expense associated with issuing the IM
for non-short-stay admissions, that is, 60% of the total Medicare fee-for-service and health plan
inpatient hospital discharges. Consequently, the total annual burden associated with delivering a
copy of the signed IM to 13 million enrollees will be 650,000 hours-not 339,000 hours-and
therefore approximates a cost of $975,000 rather than $508,500.
GNYHA is also concerned that CMS has not addressed the significant work effort that hospital
staff will expend to obtain the signature of the authorized representative when the patient is not
capable of comprehending and signing the IM at or near the time of admission. This situation
occurs often when a nursing home resident is hospitalized and/or a Medicare patient is admitted
to a critical care area. We do not believe CMS has considered the additional time to attend the
patient on the unit after admission to deliver and explain the IM. Similarly, CMS's estimate does
not capture the expense associated with contacting the next of kin by telephone after it is
determined that the patient cannot receive visitors or comprehend the notice. In addition, CMS
has not accounted for the cost associated with overnight mailing and/or faxing the IM when it is
issued via telephone.

Finally, we expect that hospitals will encounter significant additional expense to demonstrate
compliance with the new Medicare regulation. Based on preliminary conversations with hospital
staff, we are aware that many providers are planning to incorporate a carbonless paper multiple
page form or similar manual process to demonstrate compliance and to ensure that: a) the patient
signature is recorded on admission; b) a copy of the signed admission IM is retained and then
reissued at or near the time of discharge; and c) a chart copy is preserved for the medical record
(as evidence of compliance). The CMS cost estimates clearly do not reflect the additional
expense to providers to develop and purchase these specialized forms.

Enhancing the Quality, Utility and Clarity of Information Collected
The revised IM published in the Federal Register on January 5,2007, is materially inaccurate in
the following regard. Currently, the Quality Improvement Organization (QIO) is "available"
seven days a week to accept requests for appeals; however, this availability is limited to normal
business hours. The revised IM suggests that the QIO accepts requests for appeals 24 hours a
day. It would be less confusing if the IM stated: "QIO staff is available to accept requests for
appeals seven (7) days a week, including holidays, during normal business hours (e.g., 8:30 a.m.
to 4:30 p.m.). After hours, you may leave a message and your call will be returned the following
day during normal business hours." It is important to provide this distinction because of the timesensitive nature of requesting a QIO appeal and to prevent the Medicare beneficiary from
incurring any unnecessary financial liability. CMS should incorporate language that clearly
underscores the importance of requesting the discharge appeal in a timely fashion.
In addition, the revised IM does not contain a field for annotating the health plan name and
telephone number even though the draft notice instructions direct that this information be
completed. GNYHA believes that CMS should eliminate this requirement unless it mandates that
its contracted health plans designate a dedicated telephone number as a centralized contact for
enrollees who have discharge appeal questions. Because providers typically encounter an
exhaustive and confusing menu of telephone options in their daily dealings with health plans, we
believe it is unrealistic that the Medicare beneficiary will be able to negotiate the multiple
prompts in a way that is helpful and minimally confusing. Unless CMS enforces that its
contracted plans establish a dedicated phone number and posts these numbers on its Web site
(www.cms.nov), any generic number that a provider inserts will have limited value for the
Medicare beneficiary.
The revised IM should also be amended to permit hospitals that elect to utilize a carbonless paper
multiple page form to insert an additional signature line and date line to reflect when and to
whom the follow-up IM was issued.

Use of Automated or Alternative Collection Techniques
To minimize the work burden of manually annotating the IM with the patient name, patient ID
number, and attending physician, we ask that CMS accept certain automated and otherwise
simplified solutions for completing these data fields. Many hospitals utilize addressograph plates
or peel off labels to imprint patient information on each document contained in the medical
record. This information typically consists of the following data points: patient name, patient

v

account number, medical record number, sex, age, unit, date of birth, adrnissiodregistration date,
roomhed location, hospital service and attending physician's name. We ask that CMS endorse
all reasonable technology that may be available to providers in order to streamline completion of
the IM and to reduce manual work effort.
We believe that it should only be necessary to record the date once on the IM: at the time that the
beneficiary or authorized representative signs the notice. If the authorized representative is not
available to sign the notice and it is explained via telephone, it should suffice that the hospital
worker issuing the notice annotate the applicable date and that it was issued via phone.
As previously explained, patients may not be competent to understand and sign the IM upon
admission and, furthermore, may not be accompanied to the hospital by a family member or
authorized representative. In these instances, CMS should consider mail, fax, and e-mail as
acceptable alternatives for issuing the IM at admission and in advance of discharge.
We appreciate your consideration of these comments. If you have any questions please contact
Lillian Forgacs, Associate Vice President Utilization Management and Managed Care, at (212)
506-5534 or [email protected].

V