CMS-R-193 #21 and 22

March 5,2007
Bonnie L. Harkless, Room C4-26-05
Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development - C
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, Maryland 21244-1 850

RE: (CMS-R-193) Important Message from Medicare (72 Federal Register 568), January 5,
2007
Dear Ms. Harkless:
The Florida Hospital Association, on behalf of its member hospitals and health systems,
appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services'
(CMS) proposed revisions to the Important Message from Medicare (IM), as published in the
Federal Register dated January 5,2007. The revised process for the form is much improved
over that originally proposed, but we do have concerns with the draft as presented.
The first concern that we would like to raise is one of process. While hospitals are
instructed to provide the IM within two days of admission and the patient is to sign the form,
acknowledging receipt and understanding, we are concerned with those hospitals that are quickly
moving to a paperless operation. Is it appropriate for hospitals to provide the patient with a
laminated copy of the IM, discuss it with them, and then have the patient sign via signature pad?
The patient's signature would become part of a final document that could be printed and
provided to the patient. Would provision of a print out from such a system comply with the
requirement to give the patient the original signed IM?
We are also concerned about those instances when a Medicare patient is admitted to the
hospital and is unable to understand or sign the document and there is no representative available
other than by phone. What procedures are hospitals to implement in these situations?
The form indicates that the patient can contact the Quality Improvement Organization if
they are appealing the discharge decision. Will the QIOs be required to have staff available 2417
to accept patient calls? If not, this should be clarified on the form -to state that the QIO accepts
requests for appeals 24 hours a day implies that they will be staffed and that a patient calling will
not reach a recording.
The draft form allows for signature of the patient or their representative, but does not
accommodate instances in which a patient refuses to sign the IM. Previous instructions for forms
such as the Medicare Advance Beneficiary Notice require the hospital to notate the patient's
.

Corporate Office
306 East College Avenue
Tallahassee, FL 3230 1 - 1522
(850) 222-9800 Fax: (850) 56 1-6230

Regional Office
307 Park Lake Circle
Orlando, FL 32803
(407) 841-6230 Fax: (407) 422-5948

..>..

-.

Washington, D.C. Office
444 N. Capitol Street, NW, #532
Washington. D.C. 20001
(202) 434-4848 Fax: (202) 434-4846

..

* Important Message From Medicare
March 5,2007
Page 2

refusal and to have the form witnessed. There is no place on the current form for a witness
signature.
Our other questions relate to the layout and design of the proposed form and are as
follows:
When will CMS make translations of the IM available? Will this be limited to Spanish?
Will the form accommodate a patient's mark or an X if that is their signature?
The statement asking the patient to "sign below to show that you have received this
notice and understand it" should be changed to indicate "sign below and date. "
There is no space on the second page to indicate the name and phone number of the
Medicare Advantage plan, although the instructions call for this information to be
completed.
The proposed form appears very busy and we urge CMS to take a look at how this could
be better designed for ease of reading by the patient.
The FHA again thanks CMS for the opportunity to comment on the revised IM. If you
have questions on these comments, please do not hesitate to contact me at (407) 84 1-6230 or via
email at kathvGi?fha.org.

Kathy ~ e e ~
Vice PresidenttFinancial Services

NEWjERSEY HOSPITAL ASSOCIATION

March 6,2007

Centers for Medicare and Medicaid Services
Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development-C
Attention: Bonnie L Harkless, Room C4-2605
7500 Security Boulevard
Baltimore, MD 21244-1 850

RE: CMS-R-193
Dear Ms. Harkless:
The New Jersey Hospital Association appreciates the opportunity to comment on the Centers for
Medicare and Medicaid Services' proposed changes to the Important Message from Medicare
and its related paperwork requirements as submitted to the Office of Management and Budget.
The changes are proposed following the Nov. 2006 adoption of new rules regarding the process
to noti@ Medicare beneficiaries of their hospital discharge appeal rights.
NJHA believes the final rule governing the distribution of beneficiary notices is much improved
over the proposed process, but hospitals still have significant concerns regarding the
administrative burdens associated with distributing the LM. Although this public comment
period is designed to solicit feedback regarding the content of the new IM,we're also taking this
opportunity to note the concerns the industry has related to the distribution process. NJHA
requests CMS revise both the IM and the final rule to address the concerns detailed below.
Chan~esto the IM format
Clarify on the first page of the IM that beneficiaries have the right to receive "medically
necessary" hospital services covered by Medicare. The revised statement would support the
fact that clinical criteria must be met to demonstrate that the patient needs continued inpatient
services.
Include on the second page the time frame by which beneficiaries and the hospital will
receive a notice from the Quality Improvement Organization that the beneficiary is
appealing the discharge. This clarification will provide the beneficiary with a sense of when
they will be receiving the detailed information related to the rationale behind the discharge
decision, which may reduce the anxiety associated with awaiting word of the appeal decision.
Reconcile the IM and the instruction for completing it for Medicare Advantage enrollees.
The instructions require hospitals to fill in the contact information for the plan, but there isn't a
place on the form to do so.

760Aiexander Road

rn PO

Box I rn Princeton, Newjersey 08543-000 1
Tei 609-275-4000

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Comments to CMS re IM
March 6,2007
Page 2

Concerns related to the distribution process
Eliminate the requirement that delivery of a follow up IM at discharge be a copy of the
notice signed at admission. NJHA believes the intent of the follow up notice is to simply
remind beneficiaries of their discharge appeal rights, which may be accomplished by delivering a
generic, unsigned copy of the information. Requiring re-distribution of the signed notice does
not appear to provide any additional benefit to the enrollee, and is administratively burdensome
for hospital discharge staff.
Clarify hospitals' responsibility to issue additional IMs in certain circumstances. Hospitals
are concerned that they may be in the position of issuing multiple IMs to the same patient. For
example, if discharge is imminent and the patient is given a follow-up copy of the IM in
anticipation, but then the planned discharge is canceled because of a change in the patient's
clinical presentation, does the hospital need to once again deliver a third copy of the notice when
the patient is stabilized and ready for discharge again?
Once again, NJHA appreciates the opportunity to comment on the proposed changes to the
Important Messagefrom Medicare, and to communicate the concerns that remain following the
adoption of final rules last year related to the notification process. If you have questions or
would like more information, please contact me at [email protected] or 609-275-4252.
Sincerely,

Jill Squiers
Assistant Vice President
Health Planning
K:WANAGED CAREWedicare MCWODMAR\Comments to CMS re IM Proposal.doc