Comments 1-5

OMB DEP DIR MGMT

bh5 Rural Wisconsin
s9q* Health Cooperative
April 18,2007

OMB Human Resources and Housing Branch
Attention: Carolyn Lovett
New Executive Office Building
Room 10235
Washington, DC 20503

RE:

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Notification Procedure for Hospital Dischayes Comments on the Proposed 1
nformation Collections for the Important Message

To Whom It May Concern:
Rural Wisconsin Health Cooperative is owned and operated by 30 rural Wisconsin
hospitals, and as such, are committed to advocacy for rural hospitals as well as to
ensure equitable processes for Medicare beneficiaries at PPS and CAH hospitals alike.
My first concern regards the fact that CMS has noted timing of the initial or follow-up
notice to be 1 or even 2 days before discharge and when the hospital cannot
anticipate the discharge. it should deliver the IMIfollow-up as soon as the discharge can
be anticipated. In as much as the initial final rule established that discharge date
determination is more difficult to asceRain on acute care patients for a muttitude of
reasons, I question why the first page of the IM includes the statement "If you don't feel
like you have enough time to consider your appeal rights, call 1-800-Medicare (1-800633-4227),or T Y : 1-077-486-2048". This infers additional rights upon their
dissatisfaction, invites beneficiary complaints about the system, and may incite
unnecessary confusion about the appeal process. Given that FAQ under section IV Q1
has noted that hospitals may not establish policies that allow the follow up copy of the
IM to be delivered routinely to patients on the day of discharge, I encourage CMS
remove that bullet off the first page of the IM andlor to at least revise the verbiage to
only inform the beneficiary to call I-800-Medicare if there are further questionslconcerns
regarding a hospital discharge process.

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My second concern regards page 2 of the notice - Steps to Appeal your Discharge, Step
1. Here it indicates that the patient should notify the ".. .QIO no later than your planned
discharge date and before you leave the hospital. If you do this you will not have to pay
for the services you receive during the appeal (except for wpays and dedudables),"
You noted that the beneficiary must appeal before their planned discharge date -

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however, you also note that they wont be responslblelwon't have to pay far services
during the appeal. Therefore, the beneficiary could interpret this to mean that IF the
hospital gave them the notice on day 2 to be discharged on day 3 and if they
appealed on day 2, they wouldn't have to be responsible for anything after day 2, which
is even prior to the planned discharge date. The hospital should not ever be held liable
for those services provided prior to the anticipated discharge date; therefore. I
encourage this language to be more specific.

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1 also have comments regarding the timing of the notice noting liabilitylcharging issues,
Whereas this language states that the beneficiary will not be financially responsible for
services provided after the appeal, it infers that the hospital may not bill for anything
after they appeal. 1 encourage CMS to clarify if this truly infers that the hospital will not
be able to bill for services after planned discharge datetappeal date or if this means
that the patient will not be billed for those services. For example, if the patient were
delivered the notice on day 2 and decides to appeal on day three (day of discharge),
please further inform if ALL meds dispensed after appeal will be able to be
reportedlbilledto the account. I strongly encourage these serviceslmeds to be allowed
to be included within the patient eccount so that hospitals aren't burdened with
unnecessary pharmaceutical costs.

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Furthermore. if patients are not to be liable for services after the appeal, then this will

most certainly affect length of stay statistics and bed occupancies at Cniical Access
Hospitals. If CAHs are planning on discharging one or two Medicare beneficiaries in a
given dayttime period, but must keep the patient up to two days after their planned
discharge date, this will definitely jeopardize CAH's LOS and bed occupancy
participation requirements. In addition, if the Medicare beneficiary at a CAH challenges
the discharge date, and CMS does indicate that the beneficiary is not liable for charges
after the planned discharge date, then I strongly encourage CMS to further inform if
CAHs should count these appeal days as Medicare Days on their Cost Reports. As
noted the beneficiary will not be held liable, but please further instruct if the CAH will
report those appeal days as patient days andlor if inform CAH CFOs how to account for
these occasions on the Cost Report. Many rules have taken DRG payment structures
into account; however, this timing issue truly affects the CAH LOS,bed occupancy
opportunities, as well as financial reporting structures. Therefore, we strongly
encourage CMS to more thoroughly review these scenarios and provide further
specifics to CAHs.

Next, this most recent proposal informs that beneficiaries can appeal on planned
discharge date, and stay in the hospital without financial liability until at least noon of the
day after the QIO notifies the hospital, the beneficiary, and the physician of it's decision.
To apply this, this infers that the beneficiary can actually stay in the hospital for two
additional days afterthe planned discharge date. Again, one additional day to
financially absorb for PPS and CAHs will be burdensome; however, two additional days
will be a tremendous hardship. Noting the aforementioned participation requirements
for CAHs and DRG payment issues for PPS hospitals, I strongly encourage CMS to
remove the additional day AFTER the QIO notifies the hospital requirement for this

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yields no value to the patient and only senres as an additional financial burden to all
hospitals.
In summary, we support the patients need to be well informed of their rights under the
Medicare system. Nevertheless, we request that you reconsider the aforementioned
timing issues, redefjne patient liability concerns, as well as consider CAH requirements
while providing this written notice to Medicare beneficiaries. Many current aspects will
create a burden on hospitals for compliance that will escalate PPS and CAH health care
costs.

Respectfully submitted by:
Sheila Goethel, RHIT,CCS
Rural Wisconsin Health Cooperative
Sauk City Wl 53583

OMB DEP D I R MCMT

CARIPG FOR PEOPLE FIRST*

April 16,2007
OMB

Human Re6ourU& and Housing Branch
Aftenlion: Cemlyn Lovan
New Execuliv8 O f f i e Building, ROWI 10235
Washington, DC 30503
Fax (202) 395-6974
T l ~ eproposed CMS 2-step procdss requlrlng Idcilitier to rapcat fJ1eImportent Metsage Nottcc to euary Msdlcare bcnaklrry pd0r to
discharge of hls or her Medlcare rights 16 costly, lrnpraol~caland mOS( Importanlly unnecessary.
The current prowss of lsrulng (he Important Mcssage Lo beneficiaries rt the tlme of admission adequately explain, thelr r l g M to hare
the~rdi5cherge declr;on nvlewed by the local auallly Improvement Orga~ixatlon(910)r l lhey believe they are belng d k c h r r g ~ droo
soon Tne IM provides 01tbe Informallon needed by e benenctaryto request such en appeal and erglain3 they wlll not be hnancially
lieble wh119 the QIO rbvlews their osse. llthe oatlenl disagree3 wlth tha dlsdarge decrslon 8 HosplLaI.l¶~uedNotlo of N0n- avenge
adequately provldes the Madlcare beneficiary with thalr appeal righb end a l l w s them to etpress dkst;sladlon w l h an lrnpend~ng
dlscnrrge when necessary The Mbdlcare Advantega plrns ere Rqu~reQ
to asue the Nollce of D i ~ ~ h a r gand
e Medlcaro Appeal Rtghta
when 8 beneficiary d~sagreeswlth the discharge deciston These processes already prov~dcthe bencflclary wlth all of lhc necessary
Getalls regarding lheu rlghts Repeating Lhe IM nobce prror lo dlscnarge after already Issued upon admisston is re-work and lnoWc~enl
use of staff flme
The lanpuegb ofrhe proposed Qeneric dischrree nollca could cause benehoisrio lo daubt whether the planned discharge I%
aDDrODrltIfe Conscquenll~.It Ilkely will sbmulale an bncrease Jn tho number of unwarrented appeals and delayed dt~chargesaf tho
expensa of the haspbl and other patients awalllng admiss~on
The hardcopy Signaturs and record keeotnp requiramtn& ere Eounler productive to hosplfals' movement lo eleotronlc medlcal records
The process of Issuing a notlce lo all Medlmre benehdanos olfers no benefit lo rne pa1;rtnr. In reality, this may add mom c~nluslonlo lhc
already cornplax and dltrieul[ 10 undrnland health care 3y'llem for Medluto beneficiaries, If fhe p3t;ctnl 1s I0 diragreement wtlh the
dlschargs then detailing the rppeal protats and conlactlnQthe QIO n rsa~onabteend alrnady In place with the current HlNN orocess.
There are very few tnstancn in out tsdlit;ar in whkh a palien\ expresses concern over balng discharged too 9 0 ~ n .Givlng all potlenl~
3 personal Ialler and requesting a signed acknowledgement ol rrcs~pt,for lhe few instsnces of a percalved Droblcm adds an
administrative cost and is unflscarsary
The proposed discharge n o l i a proce3s Is unnecessarily burdansame because it is out of sync wlfh btafldard dlscharge plann~ngand
physician dlscharge ordrr patlrrns Physlderls, not hosphslt, make dlschage deckions, The notice repeeredly refers 10 hospitals
making discharge decisions. H0,pitals oannot dkchargs pollent8 w'llhoul a physician's dbcherge order. Hospitals opsnte a discharge
pl~nnfngp r a u s r that a governed by Medicape conditions of panicipetlon and, for most hospitals. by the Joint Commission on
Accreditatrofl of Htollhcarr Orgsnizallorrr slandardr. )n both casas, those standards require the early Iplllatlon of tho process,
~nvalvement0f lhe patlent and family in the planning, timely notice of expected dlschorgs dele, and arranpemsnh for post-xuie care.
We elgo have a oare rnanagsment program lo m u ! e appropriate a r c in the eppropriale selling. But these aalv~~las
lhal supporl care
planning and discnage dec;sions 3hould not be confused whh the eClUal dbcharge daclsion process
Adopting tho s3rns process tor a u t o care ho3pitals as are in place for skilled end long lerm laCllltlt3: makes no smse The level of
Cara and LOS Vary greatly belwaen thesbseRings.
The pepework Indicales 6 a QIO ic available for them aDMalt 2411 and they are not. Ispoke to our lacsl010 snd they indiceled lhsl
they would have o penop canying e pager batha eausl apperl process would not take place afler hours
The l o r n also ro~ulrasthat we enter the name and lelephont number of lhe MedlcaR Adventage plm. This requlremcnl adds an
addirlonal burden for the hospltal lo provlde the patlentwilh Ih~sdetail w h ~ nit IS not rmdily available.
The t h e astlmate 15 5 rnlnuteo to dallver lho letter Howavor, mora quosdons. ~ssuesmay need to be addressed wlln the palrent and the
actual avcnQe mry extend beyond 10 mlnvtes.. Tnerc rr na ~ccountlngbf the adm~nistntivellme and burden pleoed upon 3 faellRy lo
~dentlfytllc Mtdlcarb patient Ths addo stgn~ficantcost. tune and burden to !lie hcillly at an estlmate of 30 rnlnutes per pallent whtch IS
>UO,DOD It may also Leke 2-3at[empa lo deliver the [email protected] when dtoling wilh tho Medtare repressnlatlve and no1 the patloll
tnemSQl~e9In addllion, we would be foroed to develap a rnonrtoring and audit process to sssure compllnnce. which then requlres manhcurr al a cost to the organ~zaflonwltli no retufn or addrllonal bonenl to the patient
The ~ - P ~ CProeess
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may make sense for Medicarr patient: in SNF, HHA, or CORF because lyplcally thole pol~entsere ectivaly reMluing
serricc nnd care for weeks as apposed to the few days In tlle acute cars setting.

84117/2007

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Patrent B u s ~ n e c sS e r v i c e s

April 17, 2007
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Allina Hospitale & Clinics
Regulatory Aaairs
PO BOX43 hld Ro\ltc 10105
Minneapolis, hfN 55440-0CM3

ALLINA.
Horgitds & ClCricr

April 18, 2007

OMB
H u m Resources and Housing Branch
Attention: Carolyn Loven
Ne\v executive Officebuilding Room 10335
Washington, DC 20503

RE: Draft Revisions to Potm # CMS-R-193 (00/07) Important Meesage from Medicare
Dear Ms.Lovett;

On behalf of AUina Hospiuls and Clinics, I appreciate thc opporNniy to comment on rhe proposed changes to the
Important Message Gom Medicare (Ihf) Fonn. A h a Hospitals & Clinics is a family of hospitals, chits and care
services that believes the most valuable afisetpeople can have is their good health. We provide a continuum o f care,
from disease prevention ptognms, to technically advanced inpatient and outpatient care, to medical transportation,
pharmacy, durable medical equipment, home u r e and hospice senrices. A l l k serves communiries around
Minnesota and in western Wisconsin. A h hospitals submitted well over 300,000 claims innually, rcprcsenang
52.0 billion in total charges. Needless to say, we have a vital interest in providing our patients with the most up to
date and accurate information rega.rc&ng thek length of inpatient stay and potential Gnancial liability.
We commented on h e proposcd rule that the process must be efficient and not require unnecessary redundant
work. We apprecute that CMS kstened to our concerns and movcd fonvlrd with the use of existing tools.
However, we continut to hive concerns about the double notification required for patients with greater than 2 day
stays. We know that the hnal rule has been written and we will allocate resources ncccssvy to cluplicate the form
and give it a second rime to our longer stny patients but feel the need to raise our concern one more time. From a
policy standpoint we would like to 9ee Crirical Access Hospitals exempted from the second notice since the Icngrh
of stay is only 3 days. A nonce provided at admission that should be sufficient for a 3 day stay.
We have reviewed the latest revisions to the Ih4 form and have a few suggestions:
1 . Please drop the word "attendmg" horn the physician identifier line. Thc physician that adrruts the patient,
when they receive rheu iniud notice, may not bc rhc same physician [hat writes the discharge order. Plcasc
consider dropp~ngthe word "attending" and leaving it as physician.
7. Please add a blank under the signature lint on the first page. In cases where the patient is unable or rcfuscs
to s q n thc document we need a phce to document reasons why no sigmnue.

Thank you for the opportunitp to pro~ldcinput on the proposed revision to thc IM form. Please feel free to
contact me at 612-262-4912 if you hive any M u questions.
Sincerely,

"-a"*+
Nancy G. Payne, RN
Director Regulatory Affairs

TOTRL P. 12

CONT It..IUE FROM PREUIOUS PACE

001

Dear SirNadam
With regard to CMS-R-193, I would like to state that this is not necessary and adds a
workload on already overburdened staff w o r k with Medicare patients.
If a patient has n disagreement with hisher discharge then I think then is the time to work
with the patient to be sure all of hislher rights are protected. Ta go through this for every
patient regardless of whether or not there is my patient concern with being discharged is
bureaucracy st the extreme and serves no one well. It costs money, wastes paper,
confbses folks who were not confUsed and creates public relations issues where none
existed before.
If OMB must insist on adding paperwork it may be better served limiting it to when rhw
is an actual dispute.

/loseph W.Haney,

Director, Patient Business and Access
Community Hospital of che Monterey Peninsula
Monterey, California
53 1-625-4924

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Baptist Health

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9601
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721r~-7iyY
630.hit 7
snl zu2.2ooa

MEDICU CENTER
Littlc Rock

Centers for Medicare and Medicbid Sewices
Departlnent of Health and Human Sewices
Adention: CMS-4 1 05-P
P.O.Box 8010
Baltimore, MD 2 1244-1850
/

I

April 23,2007

To Whom It May Concern:
I am wiring in response to bproposed rule CMS-4105-P, Medicare Program;Notification
Procedures for Hospital Discharges. I am the Director of Case Coordinntion at Baptist Health
Medical Cmter, an 8001- bed community hospital Iocated in Little Rock, Arkansas.
a Director of Case Coordination I: have been directly involved with discharge planning for the
acute inpatient population for the past 15 years. Our curent discharge planning practices begin at

AS

the time of admission when patients are provided with the Important Notice $.omMedicare
during patient registration. Next, the admission nurses assess the patient's current living situation
and needed resources. In addition, case managers interview all patients meeting the hospital's
screening criteria: patient over age 70, Medicare beneficiaries under age 65 and patients at high
risk for needing post acute savices. Patients nnd their families are involved in discharge
planning activities and art provided with choices of agencies for post acuw services. Our process
dso includes ample opportunity for patients to change their minds,or disagree with the discharge
process and request appeals to the QIO.

The CMS proposed change places an administi-ativeburden on the hospital tlut greatly
outweighs ihe benefit CMS eaimates it will take 5 minutes to deliver the generic notice and
have it signed. If a signature is required A . the patient is NOT the decision maker,it can take
an additional day to obmin the dgnahue of h e patient's

decision maker. My recormnendation is
decision maker is not the patient.

LO allow telephonic notification of the dedsion maker when the

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Baptist Health
m1w CENTER
Linle Rock

In addition, delivery of the fbllow up copy of t h 11npomnt
~
Notice earn Medicare also poses an
unnecessary financial burden on the hospital. In addition, access to post-acute carc facilities
(LTACH,SNF,AcuteRehab, & Hospice) is not within the control of the hospital. Beds in these
facilities are in great demand and can be diff~culrto locate. Once a patient is accepted, the postacute care facility expects the patient to be transferred or the bed may be assigned to another
parienr. Delays in discharge andfmtransfer to post-acute facilities can result in man greater (ad
inappropriate) lengths of stay in acutecare hospitals. No one wishes for the patient KOmiss the
opportunity to receive the appropriate level of carc.
I11 our hospital the average LOS is 5 days. Since lengths of stay are shon and patient's conditions
can stabilize quickly, it becomes difficult to predict a discharge one day in advance. My
recommendation would be for the hospital to notify the patient by 12 noon on the day of
expected discharge and allow the patient to appeal the discharge by 5:OOPM that evening I
bdieve this provides the patient ample time to consider the discharge and notify the QIO if they
would like an expedited appeal. Many patients are discharged from the hospital in 1-2 days, very
soon after the patient bas received their Medicare rights information during the admission
process.

I have read t l ~CMS
t
estimates only 1-2%of beneficiaries will request an expedited appeal, if
this is true, it would not be overly burdensome for hospitals to compIcte the derailed explanation
of Hospital Non-Coverage. I m concerned that this may be a gross underestimate as patients
become more aware of how easy it is to continue their hospital stay. My recommendation would
be for CMS to insdmtc this rule on a temporary basis to judge the actual impact on hospitals. If
only 1 - 2% of patients request the expedited appeal and significant percentage of the appeals arc
upheld then it is apparent that CMS has acted in the best interm of the public. If the percentage
is significantly higher and nearly all appeals are overturned, then it becomes apparent that this
proposal did nor yield the expected results. and indeed, the increased costs (administrative and
LOS)do not justify rhe means.
I appreciate the role of CMS in safeguarding patient rights. We believe we musr protect patient
riars while also stewarding govaamurt resources and emuring patients do not take advantage
of an opportunity to unntccssarily extend a length of stay adding significant costs to Medicare.
Sincerely,

sandy Guthrie, Director Case Coordinanon
Baptist Health Medical Center
Linle Rock, Arkansas