CMS-R-193 Comments #17 thru 20

Page 1 of 2

Harkless, Bonnie (CMSIOSORA)
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From:

Harkless, Bonnie (CMSIOSORA)

Sent:

Tuesday, March 06, 2007 5:24 PM

To:

'[email protected]

Subject:

RE: Comment on a Revised Version of the Important Message from Medicare

Importance: High
Tracie,
Please refer to the process as noted in the January 5, 2007 Federal Register notice for submitting comments,

"

To be

assured consideration, comments and recommendations for the proposed information collections must be received at the address
below, no later than 5 p.m. on [OFR-insert

date 60 days after date of publication in the Federal Register.]

CMS, Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development - C
Attention: Bonnie L Harkless
Room C4-26-05
7500 Security Boulevard
Baltimore, Maryland 21244-1850"
Electronic comments are not accepted. Please overnight your comment to my attention. If I receive the comment tomorrow 3/7/07,
with a postmark of 3/6/07, it will be accepted, otherwise it cannot be accepted. Please let me know if you have any additional
questions.
Thank you.

PRA Analyst
Office of Strategic Operations and Regulatory Affairs
Centers for Medicare and Medicaid Services
(410) 786 5666
[email protected]

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From: [email protected] [mailto:[email protected]]
Sent: Tuesday, March 06, 2007 4:55 PM
To: Harkless, Bonnie (CMS/OSORA)
Subject: Comment on a Revised Version of the Important Message from Medicare

Kaiser Permanente appreciates the opportunity to review and comment on the revision to the Important Message from Medicare
(IM) that was issued on January 5, 2007. Our comments are listed below. If you have questions or need further information,
please contact me. Thank you for considering our comments.
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We would like to suggest moving the signature to the end of page 2 to ensure member reads all the information, including
the appeal instructions.

Page 2 of 2

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We would like to suggest CMS specify a hour during the day as a deadline for the member filing the appeal - ie:noon of
day of discharge. Without a reasonable deadline, the member can wait until 8 pm the day of discharge when there will not
be support services in the hospital or at QIO to process the appeal request. This will delay records beivg sent and
decisions being made and increase unnecessary lengths of stay in hospital.
We would like to suggest CMS implement a time rule that the hospital needs to inform the member of discharge by. For
example, the member must be notified by 6 PM on the day before the discharge date. This would ensure the member had
enough time to consider whether to appeal the discharge by the filing deadline.
We would like to suggest clearly defining the difference between "Original Medicare" and "Medicare Health Plan". Can
CMS add the word Advantage or bracket a section to depict the type of MA plan the member is on, e.g. Medicare
[Advantage] Health Plan?
Does there need a place to note the date you gave a second copy of the notice to the member should they stay beyond 2
days?

Suggested changes to the actual IM:

Tracie Klingenberg
Project Manager, National Medicare Compliance
National Compliance, Ethics 8 Integrity Office
Kaiser Foundation Health Plan, Inc.
office (503) 813-4119
fax (503) 813-4912
[email protected]

Page 1 of 1

Harkless, Bonnie (CMSIOSORA)
."

From:

[email protected]

Sent:

Tuesday, March 06,2007 4 5 5 PM

To:

Harkless, Bonnie (CMSIOSORA)

Subject:

Comment on a Revised Version of the Important Message from Medicare

Attachments: suggeted changes.doc

Kaiser Permanente appreciates the opportunity to review and comment on the revision to the Important Message from Medicare
(IM) that was issued on January 5, 2007. Our comments are listed below. If you have questions or need further information,
please contact me. Thank you for considering our comments.
I

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We would like to suggest moving the signature to the end of page 2 to ensure member reads all the information, including
the appeal instructions.
We would like to suggest CMS specify a hour during the day as a deadline for the member filing the appeal - ie: noon of
day of discharge. Without a reasonable deadline, the member can wait until 8 pm the day of discharge when there will not
be support services in the hospital or at QIO to process the appeal request. This will delay records being sent and
decisions being made and increase unnecessary lengths of stay in hospital.
We would like to suggest CMS implement a time rule that the hospital needs to inform the member of discharge by. For
example, the member must be notified by 6 PM on the day before the discharge date. This would ensure the member had
enough time to consider whether to appeal the discharge by the filing deadline.
We would like to suggest clearly defining the difference between "Original Medicare" and "Medicare Health Plan". Can
CMS add the word Advantage or bracket a section to depict the type of MA plan the member is on, e.g. Medicare
[Advantage] Health Plan?
Does there need a place to note the date you gave a second copy of the notice to the member should they stay beyond 2
days?

Suggested changes to the actual IM:

Tracie KlingenbeQ
Project Manager, National Medicare Compliance
National Compliance, Ethics 8 Integrity Office
Kaiser Foundation Health Plan. Inc.
office (503) 813-4119 fax (503) 813-4912
[email protected]

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

ii You have the right to receive necessary hospital services covered by Medicare or covered
by your Medicare Health Plan (your "Plan") if applicable.

ii 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.
fi

You have the right to receive services you need after you leave the hospital (that is, after
you are "discharged"). Medicare or your Plan may cover some of these services if ordered
by your doctor or your Plan. You have a right to know about these services, who will pay
for them, and where you can get them.

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 or Plan decides you
no longer need hospital care or can safely receive care in another setting, you will be informed
of your discharge date.

If you think you are being discharged too soon:

1

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

ii You also have the right to request an appeal and have your hospital services covered
during the appeal. An independent reviewer called a Quality Improvement Organization
(QIO) will give you a second opinion about whether you are ready to leave the hospital.
ii You should contact your QIO as soon as possible after you are informed of your discharge
date, but before you leave the hospital. If you contact the QIO by your discharge date, your
hospital services will continue to be paid during the appeal (except for charges like your
coinsurance and deductibles) until noon of the day after the QIO notifies you of its decision.

Page 2 of this notice gives you more information about the appeal process and how to contact
your Q10.

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

Signature of Patient or ~epresentative

Date
CMS-R-193

(Revision Date)

HOW TO ASK FOR AN IMMEDIATE APPEAL OF YOUR DISCHARGE
A

1

If you want to request an appeal, you should contact your 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 ~ o o p :-_i your discharge
date, your hospital services will continue t o be paid during the Q10 review until at
least noon of the day after the Q10 notifies you of its decision.

fi Here is the contact information for the QIO:

{insert name and number of
he QIO accepts requests for appeals 24
. You may also call the QIO if you have

questions about the appeal process.

fi If you request an appeal, you and the QIO will both receive a notice that explains the
reasons that your doctor, the hospital, (and your Plan, if applicable) think you are ready to
be discharged.
A

The QIO will ask for your opinion and look at your medical records. 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.

fi The QIO will notify you of its decision within one day after it receives all necessary
information.
o

If the QIO finds that you are not ready to be discharged, Medicare will continue to
cover your hospital services until further notice.

o

If the QIO finds you are ready to be discharged, you will be responsiblefor payment
of your hospital services beginning noon of the day after the QIO notifies you of its
decision.

YOU HAVE OTHER APPEAL RIGHTS:

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services you receive after your planned date of discharge. If the QIO decides your
Medicare coverage should continue after you have made payments, you will receive
a refund.
o As for any Med~careservices, a claim for your hospital services w ~ lbe
l submitted to
Medlcare by the hospital. You will get a Medicare Summary Notice (MSN) regard~ng
Medicare's decision on the claim and your right to appeal that decision.
A

If you belong t o a Medicarefit?:vs~~~cJ1
Health Plan:
11 your discharge date, you may still ask for
o If you do not request an appeal by
a fast appeal from your Health Plan. However, if your health plan decides
discharging you was the correct decision, you may be responsible to pay for any
servlces you receive after your planned discharge date.
a

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Consult your Medicare Handbook or call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877486-2048 for more information about this notice and the Medicare claims appeal process.
Accordln ' to the Pa eruorh Reduct~onAct o f 1995 no persons are requ~redto respond to a collect~onof lnformat~onunless 11 d~splaysa kal~dOMB control
number %he vahd ~ M control
B
number for thls lniormatlon collect~on1s 0938- 0692 The ttme requ~redto complete thls ~nformatloncollection IS
estimated to average 17 8 mlnutes per response. lncludlng the tlme to revlew lnstructlons search exlstlng data resources, gather the data needed, and
collect~on If you have comments concemlng the accurac o f the tlme est~mate(s)or sug lestlons for lmprovln this
complete and revlew the ~nformat~on
form. please wrlte to CMS. 7500 Securlty Boulevard, Attn P R 4 Reports Clearance Officer. d l l Stop C4-26-05, Balt~more.klaryland 21244-1 85Cf

Formatbed: Font color: Red

I ~ ~ O VHEALTH
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SYSTEM
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8 1 10 Gatehouse Road
Suite 200, East Tower
Falls Church, Virginia 22042- 1210

Tel 703 289-2000

Questions and Comments Regarding the Discharge Notice Important Message
Prepared by Linda Sallee, MS, RN, CMAC
Vice President, Case Management and Infection Control
Inova Health System
Falls Church, VA.
1.

Since patients who are admitted from the emergency department are not re-registered
by the admitting staff, the department who will issue the initial notice, we are requesting that
we be allowed to give the notice to every emergency department patient so we will not miss
providing a notice to any of these patients. The same issue does not apply to the observation
patients because it is Case Management who works with physicians to make these status
changes and can issue the notice when the status is changed. I am concerned we will miss
the required timeframe if we do not have the ability to issue the notices to all ED patients.

2.

We have begun designing our processes to meet this regulation and would like to pilot our
new processes in June. We understand we would need to run dual processes in order to do
this pilot but it would help us work out the bugs prior to the required implementation date.

3.

This is a new process and has multiple points at which there may be a breakdown related t
the timing. Will there be penalties for missing the timeframes even though we are trying to
adhere to the requirements?

4.

Based on information from our QIO, the continued stay HINNs will no longer be used. Does
this also include the Preadmission and Admission HINNs? Will we need to keep any type of
HINN log for the QIO? I believe we will continue to need these HINNs for those patients
who never meet medical necessity criteria but will not cooperate with discharge planning or
do not understand the 3 day rule for skilled nursing care. Physicians often do not understand
this rule as well.
Currently, when a patient no longer meets medical necessity and our physician advisor
concurs but the physician refuses to discharge the patient, we are able to ask the QIO for
review and the patient becomes responsible for the bill if the QIO agrees with our findings.
It appears that there is no longer a process for this type of review. The regulation as I
understand it states that we are to give a copy of the notice to the patient no later than 2 days
before discharge. Since only a physician is able to discharge a patient, must we wait until
they agree to discharge? I believe we should be able to use medical necessity criteria in
some way to assist us so that our length of stay does not increase significantly. We have
physician advisors for our case managers and they do confer with the attending physicians
but only the attending is able to discharge the patient.

6.

When we have Medicare patients who move to or from acute rehab or behavioral health
inpatient stays, the patient is discharged form one level of care and admitted to the other.
Will we be required to give another letter when they move to this other unit, even if it is in
the same building? Mental health patients may not be in a condition to understand the notice
and giving them this notice could be detrimental to their progress in some instances. Since
they are not paid DRG, is the requirement different? Would we continue to use the HINN in
that case? I recommend that we continue to use the HINN process for admits to behavioral
health and that the initial notice be accepted with the discharge notice criteria coming into
play at the time of discharge (i.e. issue the copy) if the receiving unit is in the same building.

7.

As I understand it, if the patient is issued an Important Message (IM) on the day of admission
and is discharged on day 3 of the stay, a copy of the IM is not needed. If, however, they are
discharged on day 4, a copy would be needed on day 2 of the stay.

8.

On many occasions, the IM would be issued during the admission process and the physician
and case manager would have discussed a discharge plan and date. The patient then
improves more quickly than expected or they are appropriate for a Long Term Acute Care
Hospital (LTAC). As the rule stands today, we would not be able to discharge the patient for
2 days until the copy of the notice can be issued. Not only does this increase our length of
stay but may lead to the patients' recovery being delayed. For example, the patient is on a
ventilator and not doing well with the weaning protocol. We know that the LTAC has a very
aggressive weaning protocol with very good outcomes. We are proactive in our discharge
planning and have an LTAC accept the patient and offer a bed tomorrow. Would we not be
able to transfer the patient until 2 days due to our not providing the IM yesterday? In this
case, the patient technically still meets inpatient medical necessity criteria but they can
receive the care at an alternate level of care. Another example is a patient who is on multiple
IV antibiotics. They received the IM on admission and today the physician discontinues 1
antibiotic, changes one to PO, and leave one at IV two times a day. The patient, with a
capable and willing caregiver, could be managed at home or in a skilled nursing facility for
the completion of the antibiotics. Based on the new rule, this patient must remain in the
hospital for 2 more days.

9.

With observation patients who are admitted to inpatient, I believe we should issue an IM on
the day they become an inpatient. When we are counting days to issue the IM, does the
observation day count at all?

10.

Which languages will the IM be translated into? Will you post all the translated IMs on the
website?

1 1.

The current IM on the website asks for TTY numbers for the hospital and the QIO. We do
not have anyone at the hospital who mans a TTY to know if a message is coming in other
than in an emergency and the QIO does not normally provide a TTY, will the QIO and
providers be required to have a TTY that is manned on a regular basis. This would be very
hard to comply with as the staff who will be providing the copy of the IM within 2 days of
discharge do not stay in an office but are up on the patient units. If we could use a fax
number instead this would be helpful.

Thank you for your consideration of these questions and comments.

DE FAIRVIEW

Fairview Health Services
Patient Financial Services
P.O. Box 147
Minneapolis MN 55440-0147
(612) 672-6724 Fax: (612)-672-6454

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Centers for Medicare and Medicaid Services
Office of Strategic Operations and Regulatory AfYiiirs
Division of Regulations Development - C
Attn: Bonnie L. Harkless
Room C4-26-05
7500 Security Blvd
Baltimore, MD 2 1244-1850
Re: Important Message from Medicare, Document CMS-R-193. Comment Request
published in Federal Register January 5,2007 (72 FR 568-569)
Dear Ms Harkless,
Fairview Health Services, which has seven hospitals in Minnesota, wishes to thank you
for the opportunity to comment on the proposed changes to the process for the Important
Message from Medicare. Our comments are as follows:
Initial delivery of notice:
Currently, the notice is given on admission or shortly thereafter by registration staffor
hospital volunteers in some instances. Based on experience with this patient population,
this notice will generate quite a bit of discussion, concerns, and questions that the staff
may not be able or may not be the appropriate staff to answer, particularly during second
and third shifts. This will push the notice delivery to nursing or day staff
For admission staff to take a minimum of 13 minutes to get the signature and explain it to
the patient andlor representative will back up the admissions process. It will delay other
admissiondregistration processes, causing dissatisfied patients, as well as dissatisfied
staffwho are waiting for the information in order to be able to start the processes
necessary to start treatment.
The result is additional costs, such as more staff to avoid the backups on registration, or
to push this to clinical staff, which is another administrative burden which interferes with
their primary duty which is patient care.
We would like to point out that a signature does not necessarily mean comprehension.
On admit, patients are sick and nervous, and family member are concerned. They may
nod comprehension and then not even remember it, even if a copy is in their documents.
These types of notices are often found in the trash.

Comments to CMS
Important Message Erom Medicare
Timing prior to discharge:
We commented previously on the standard discharge notice. For all the same reasons, we
cannot predict when the discharge will happen. Hospitals do not make this decision;
physicians make the decision based on clinical criteria. When the patient meets criteria,
the patient may be discharged. Some patients recover more quickly than expected. Some
may be expected to go home and then do not. In short, discharge is impossible to predict.
Ifwe give the patient the notice and s h e does not go home as expected, we may end up
having to give it again if the patient stays longer than two days past the time we gave
them the copy. A patient who has already received the notice and then the discharge is
delayed may require assurances that we are not going to send them home just because
they did not meet the expected date or time.
Giving the patient the notice again will most likely generate the exact same questions
they asked when they first got the notice, so we would expect at least another 13 minute
conversation, using CMS' figures. Under the Conditions of Participation, we already are
required to do discharge planning so that the transition to home or another facility or
further care is smooth and patients understand next steps. Pushing this form in front of
them again could cause patients and families to doubt the process, generating more
questions, worry, and unnecessary delays, and causing further backup for other patients
awaiting admission. For those who actually do decide to appeal to QIO, we will have
unnecessary - and uncompensated - inpatient days while we wait for a QIO decision.
The process:
There is no proof that we actually gave the patient another copy without initials and some
form of documentation and a place to put the date. Just giving it to the patient therefore
serves no purpose, other than we can say it's our process.
We will not be able to get this form for emergency transfers. We anticipate that there
will be other times when we cannot get this form, such as incapacitated patients with no
family present. We anticipate that some people will simply refuse to sign the form.
Assuming CMS goes ahead with some form of this notification, we would like guidelines
for exception processing.
The handoff and tracking of this signed form so that it's available to the people at
discharge is onerous. It will require that someone physically walk this over to the patient
chart and place it there. There will be additional time involved in this process, which is
hard to estimate since process flows for charts differ by hospital and probably by patient
care unit. It will require a paper chart since this is not an electronic item, other than
possibly it could be scanned, but considering that it may be needed within a short time
frame, it could not be scanned in the normal process. It would have to be scanned
immediately.

Comments to CMS
Important Message from Medicare
For a medium sized hospital with 20 to 25 admits a day and assuming 20 to 25 discharges
per day, and using CMS' time figures, this will take the equivalent of one F'IE per day.
This assumes that there are no additional questions, and no QIO appeals.
Conclusion:
We feel that this is an unnecessary second step. Ifthere are concerns about the discharge
process, CMS should address them in discharge planning.

Thank you for the opportunity to comment.

Wh*
Steph ie McDonald
~ompiianceSpecialist
~ai&iew~ e a G hServices
Corporate Ofice
400 Stinson Blvd
Minneapolis, MN 55413

University of Minnesota Medical Center, Fairview
Fairview Southdale Hospital
Fairview Ridges Hospital
Fairview Northland Regional Hospital
Fairview Lakes Regional medical Center
Fairview red Wing Hospital
University Medical Center, Mesabi

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Albany, NY 12206-1057
www.cdphp.com

February 28,2007

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
Dear Ms. Harkless:
As requested by CMS in its January 5,2007 Federal Register request (Page 568), set
forth below are comments concerning several sections of the proposed revised version of
the "Important Message From Medicare" (IM) (CMS-R-193). For your ease, I have
restated the relevant sections commented on in italic typeface and typed the language of
concern in red typeface.

COMMENT 1
You have the right to receive services you need after you leave the hospital (that is,
after you are "discharged"). Medicare or your Plan may cover some of these
services ifordered by your doctor or your Plan. You have a right to know about these
services, who will pay for them, and where you can get them.
Discussion: We recommend deleting the words "or your Plan" in the third bullet point
under the section entitled "Your Rights as a Hospital Patient". Use of those words
implies that a Plan can order services. Health plans are not legally permitted to order
services for patients. Suggesting to a patient that a health plan can order services creates
confusion for patients in an area that health plans and practitioners have worked for years
to clarify. It is detrimental to patients for them to believe that health plans can order
services when only the physician can write an order for medical services.

COMMENT 2
Planning For Your Discharge: During your hospital stay, the hospital staff will be
working with you and your doctor (and your Plan, ifapplicable) to plan for your
discharge and arrange for services you may need after you leave the hospital. When
your doctor or Plan decides you no longer need hospital care or can safely receive care
in another setting, you will be informed ofyour discharge date.

Discussion: We recommend deleting the words "or Plan" because the Medicare
Program; Notification of Hospital Discharge Appeal Rights; Final Rule, specifically
states that physician concurrence is required, 5422.620, (d), therefore it is the physician
who determines that discharge is appropriate.

COMMENT 3
The Hospital Discharge Appeal Rights Final Rule states that prior to discharge the
enrollee will be advised of discharge and receive a copy of the signed Important Message
@om Medicare. The Rule does not identiJLhow receipt of this information is
documented.
Discussion: We recommend adding a second signature line for the enrollee on the
Important Message fiom Medicare form as well as a field for the discharge date so the
enrollee can sign the form a second time thereby creating documentation that the enrollee
received the copy of the signed notice and was advised of the intended discharge date.

Thank you for allowing us the opportunity to participate in this public comment. If you
have any questions, please contact me at 5181641-3425.
Sincerely,
ii,
Deborah C. ~ a n ~ i n e l RN
Quality Coordinator
Medical Affairs Division
Capital District Physicians7Health Plan, Inc.