Comments 6-10

@ ,p

Harkless, Bonnie (CMSIOSORA)
From:
Sent:
To:
Subject:

Lovett, Carolyn L. [[email protected]]
Monday, May 07, 2007 11:03 AM
Harkless, Bonnie (CMSIOSORA); PARHAM, WILLIAM N. (CMSIOSORA)
FW: Comments to Important Message and Detailed Notice

Attachments:

IM comment letter-due May 5- 2007-final.doc

IM comment
etter-due May 5- 2

----- O r i g i n a l Messa8;e----From: S h e r i K r u e g e r - 3 i ) : [ m a i l t c : : .c;ii x9 frn'th.~d1,1]
S e n t : S a t u r d a y , P a y 05, 2007 5:10 F:M
To: L c v e t t , C a r o l y n T , .
Cc: Nancy S c h a l l e r t ; R o b e r t a N a v d r r o ; C a t h e r i n e N e l s o r ~ ; Deb Gordon
a n d [let s i l e d Idot i c e
S u b j e c t : Comments t.o Iixpor L ~ r ~ lC4e~.jaq15
Hello,
F r o d t e r t h r d Con!muni t ; j H e a l t h , i ~ ; p r . - c : i . a t r i sthe? c p p o r t ~ l r ~y i t o comment on t h e A p r i l 6 t h
F e d e r a l Re+ s t e r rtc1t:ize.
P l e a s e se- t h e att:a:hc;(i i o n ~ n e r l : : , ~ .
We w i l l 3150 f a x ;I ::oyiy.

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Thank. y o u ,

S h e r y l K r u e g e r n i x K N , BSN, CFPQ, fCPM
P a t i e n t C a r e Cornp1iani::e Consuj~t8-3rlt
F r o e d t e r t a n d Cornm~iriit. y H e a l t k ~
a t Cornrncnity Memorial H o s p i t a l .
o f f i c e p h i ~ r l e : 262-257-1495
pager:
414-590-5530
ernail a d d r e s s :
s d i x l i f r r ~ l ke~d. u

C c n f i d e n t i d l i t y Notiit::: ? ' h i s e-!nci il message, i n c l u d i r!g arl;,: a t t a c h m e n t s , i s f o r t h e s o l e
u s e o f t h e i r . t e n d e d r - e ( : i p i e n t ( s ) ai:d may c o n t a i n c o n f i d e r t i a l a n d p r i v i l e g e d i n f o r m a L i o n .
Any u n a u t h o r i z e d r e v i e w , u s e , d i s c l o s u r e o r d i s t r i b l t i o n i s p r o h i b i t e d .
I f yoc a r e n o t
t h e i r i t e n d e d r e c i p i e n i , p l e a s . ; corit-act tie , s r r , d e r b y r e p l y e - m a i l a n d d e s t r o y a l l c o p i e s
of t h e o r i q i n a l m e s c a ~ ~ p .

Froedtert & Community Health
Comments to April 6, 2007 Federal Register/ Vol. 72, No. 66

May 2,2007
OMB desk officer:
OMB Human Resources and Housing Branch
Attention: Carolyn Lovett,
New Executive Office Building.
Rooni 10235,
Washington, DC 30503
Fax Number: 202-395-6974

RE:

Cornment.~.
for Medicare discharge notice changes

Dear Ms. Lovett :
Froedtert & Comniunity EIealtIi, Inc, Milwaukee, Wisconsin, ("F&CHW)appreciates the opportunity to
provide comments on the Notification Procedures for Hospital Discharges- Important Message from
Medicare notice published in tlie April 6,2007 Federal Register1 Vol. 72, No. 66 and the Detailed
Notice of Discharge. The following coniments and questions regarding the proposed procedures
which were compiled by key clinical and financial representatives of Froedtert and Co~nmunity
Health. Your consideration of these comments would be greatly appreciated.

IMPOR'TAN'I' \lk:SSAGE: FRO31 MEDICARE: - FORM REF'ISIONS
F&CH supports the AHA recoinlnendations for the following actions to minimize the administrative
burden of this new notice and process:
Eliminate tlie requirement that the repeat notice at discharge be a copy of tlie notice signed
at ad~nission.Since bcndiciaries would receive a copy of tlie 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 agree that it would be significantly Inore efficient to si~liply
print thc notice as part of their discharge instruction package.
-1.0 adtl to the A H A commen~s.\\e \vould ad\,ocate tliat tlie copy or second letter not be required.
The administrati\ e costs nt this second notice are extraortlinar) and unnecessary.
?.
I lie second lloticc. in \~llate\cl.f c ) r r ~ ~is. duplica~ionof\vliat \v\;o~~ld
be providccl to the patient
within t\+odaks o f adniissiol~.Is tllc piirpo,e of the notification process to provide i11formation
to \.liepa~ienton tlicir tlischarge right.; (\vI~icl~
tlle lirst notice adequately does). or is it to
encourage thc patic~itill considering an appcnl ofthcir discliargc (\\.l~ich
dclivcring for a second
time tlie sanic infolmation already probided to rhc patient seems to suggest).
After the tirst year of implementing this new process, perfonii an evaluation of whether the
new proccss has yielded sufficient benefit to warrant this significant increase in
administrative costs. Too often, administrative requirements are adopted to address
anticipated or perceived prcd-dems. 'l'hal 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 requirenlent for beneficiaries to sign for receipt of the notice; that too was
found to be unnecessary and subsequently eliminated.

Froedtert & Community Health
Comments to April 6,2007 Federal Register/ Val. 72, No. 66

Provide significant latitilde to liospitals in how they provide tlie notice to beneficiary
representatives if the beneficiary is unable to receive or understand tlie notice. This issuepage 2$
was raised during colnment on tlie proposed rule. and tlie preamble discussion of the final
rule indicated tliat CMS planned to provide guidance regarding ho\c hospitals and health
plans may deliver the appropriate notice in cases where a benet?ciary's representative may
not be iln~nediatelyavailable. Such guidance was not included in tlie instructions for the
notice. We urge CMS to allow hospitals to use any means of communication (telephone, fax.
eniail. etc.) necessary to co~iducttlic notice process with be~ieficiaryrepresentatives and
allow record notations \+lien tiicse alternatives to in-person notice are used.
(AHA, 12eslicNorwalk. March 6, 2007)
t &C't I \+0\11(1 ,idcl lo [lie : I t IA colnriient to rcqi1e4t li~r~licr
clarilicatio~ifor lioapitals to address
\ \ lierebq a be~icliciar>is "unable" to receiic [lie notice or "understand [lie notice".
tlie situn~io~i
& Iin4 no I-cncticiaq rcprc.serir:~ti\e(I'OA or I Icallli Cart Agc~it)cur~.e~itlq
i n place.

NOTIFICATION I'ROCEDURES FOR HOSPITAL DISCHARGES - DETAILED NOTICE
O F DISCHAH(;E

F&CH continues to share concern that iftlle detailed notice of discharge is issued, there should be
minimal or no grace days offered. l'lie financial responsibility of tlie patient should begin the day
after issuance. dependent on the speed of tlie QIO decision.
FORM REVISIONS:
I. 'There is not a signature line for authentication of patient/ representative receipt. Similar to the
statenlent on tlie IM forni:
Keco~iiniendinclusio~iat tlie end of tlie detailed notice:
Signature of Patient or Kepresentative Date
If this is co~t~pleted,
coi~ldreliio\,e notice date froni tlie top sectio~i.

Once again. Froedtert & Co~nmu~iity
tlealth, Inc. \sould like to extend its appreciation to you for the
opportunity to comment on the a b o ~ ematters. If you have any questions or concerns about the
co~nmentswithin. please feel free to contact Nancq Scliallert at (313)805-2859 or via email at
~iscIialIe@~finlli.edu.
Sincerely,

Nancy Schallert
Director of Compliance and Internal Audit
Froedtert and C'oni~iiunityHea ltli
9200 West Wisconsin Avenue.
Milwaukee. WI 53226

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Qf Mediciare Advocacy Project

1

13mndng our mrdicue rights.
Greatat BO? on Legal Services
197 Frknd :trod Boston, MA 02114
(617) 371-li 3! 4, ~t t o l l - f t (800)
~ 3293205

FAX (617) 3//I91222
ww,gbIs.a ;g

OM3 Desk Officer: OMB Human Rcsources and Housing Branch
Altentjon Icarulyn Ltrvetr
Ncw ~xecbrivcOffice Building
Room 10@5
Washingt((n,DC 20503
Fur numb :r: 202-3535-6974

Ra:
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Tmporrsnt Messagc horn Medicarc, CMS-R- 193 (OM#:093-0692):
Detailcd Notice ot' D~schuge.CMS-10066 (OMB#: 0938-New)
72 Fcd. Keg. 17 169 (Apri I 6.2007)

Dear MadSrm or Sir:

The Medicarc Adv(~;acy YmjecL, Grcarcr Boston Lcgal Services. works to insurc that
~assschd)ettsMedicare bcncfic1arir.u rcccive the Medicare and Medicare-1-elatedcovcrage and
scrvices I which they a a entitled. Our clients include individual and gmups OF cldcrs and
persons S ~ t hdisabilirics, especially those with low incon~rs.On behalf of our clienls, we would
likc ra sullmil he follow~ngcammcnts regarding the Ctnterlt for Mkdicarc 14Medicaid Scrviccs'
(CMS)d ; . - L notices for Mcdicare and Mcdicare Advantiigc hospital inpatients: Tmptrrrunr
Messu~cjiwnt Medicare (TM) and Detnilkd Nrrlicc ofDischurgc.

P

Ovcrall, die draft notices are clcucr and more understandable lhan prcvious vtrsion.~.Tn
parricular;the description of discharge iighu in rhc (1M)is more prominent, concise and uscful
icr paticnq I. Additionally, the information aboul paricnt liabi lily pending appeals is clearer and
easier to tolnden~and.
We suggcbc rhc following revisions to the notices and additions to inslruc\ions in ordcr to help
patienrs timefit when they receive a copy of their signd LM priol- tcr discharge. to make the
noticcs e)'en morc readable and user-friendly. and to insure limely dclivcry of this nrjticr.

Belp Patients Bcnclit From thc JM Upon Discharge.
W e i4r concerned chili upon receiving s copy of their signcd LM p i o r to discharsc ("follow
up notice"), many patrents will fail to read O r usc it because they will not realize [ha!. ir relatc~fa

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May 1 ,20(17
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[hcjr impdlding rlischalps. To help patients bcncfit from the follow up nolice, w s suggest the
followi~ig:

ch inge the tirle of thc 1M to include the word. "rhscharge'

( ~ e . ,"At1 irt~ponun~
Mtrroge
Fr;/m Mct/icure aboirt Your Inpariarr arid Discliurge Riylt1.t "1;
In Ihe firsr sectiun listing hospital inpartcnt righ~s,add a b d l e ~alerting persons rhar they
wiil r e c r i v ~a copy of their signcd notice prior to discharge; and
Keiuirc hospituls and Medicare Advantage plans to deliver thc follow up nocicc and
exlilain irs relevance when patients arc told of thcir discharge.

11.1thc M4ch 23,2007, Rcuision.' to rhe llnporlanr Me.rsugelrom Mrdicure. CMS indicarcs it
a d d 4 the,' ul\cr kui~vgpersona lo call 1-800 Mcdicue r I:thcy have indut'ftcient 6mr to consider
therr rishq , to address conccrns "that benehciarics may bc given the noticc o n their way out of
the l l q y i t jl.** WCquery, ~OWCVCI-,whcther this i n f o r d o n will actually help pahents. First,
CMS has /lot indicated ihvt 1-800 personnel have thc authority to cxtend the dcadline for patimrs
ro file a QIO appeal, Second. cven i f 1-800 pcrstrnncl have the aurhoriry to jn~ervcnc,it is no1
always pa jsi ble to reach u live person on a timely baqis. We rhereforc suggest thal lhis bullet be
dcleted.

P

Make the Notices More User-friendly and Keadable
As we meptioned ahavc, rhc nalrccs are generally clear and undersmdablc. To make thcm Inore
ctrncise a\ (d uscr-friendly, we mcnmmend thc following:

In the ,M,bold the dcadlil~elor rcqueso'ng QIO review la call the reader's atrcntion to
tti 5 c~ilicalinformation;
Tn the IM. dclcte the h~lllctadvising patielits ro contact 1-8110 Mcdicare if [hey do not
th nk they havc sufficimr time t o appcal, for the reasons mentioned above:
Ri:quiret h a ~inf'ormatioii wrirtcn into rhc Derailed Nulicc of Discharge hc legible.

Ensure 'l imely Delivery or the cT~llow
up Noticc" so Patienls who want to will have the
Opportu jity Cr, Exarcisc their Appcal fights
Accordins tn L ~ xgulations.
C
hospitals and 111;msmust deliver thc follow up noticc as far in
advancc ( ~discharge
f
as possible, but not more than 2 calendar days before discharge." 42 C.F.R,
49 405.11105 [c)(l); 422.620 (c)(l). Bwause there is no deildline for delivering this notice, Our
conccrn I ; that many paticnts could rcccive it ~ o olatc. after thcy have lost uny mcaningul
opportuq'ty LOcxcrcise thcir appeal rights. Notices will be uselcss to patients i f rhcy nrc
delivcrcd as they are packing to leavc or being whklcd out Lhr door.

'I'o prnmlrte the timely delivery of the follow-up nalicc. we suggesr thc following:
K q u i r c that the patient's signature, with date and lime of delivery, hc obtained on thc
frillow-up notice and that i~ copy be kepr in the patient's rccord. The information could

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IIe.derNar ;re
May I, 2oii7
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bc lkcorded in the "Additional Infomaion" sccliun. This will allow CMS to monitor
whin the no~icesarc actuillly dclivercrl, will discourage hospitals from delivering noticcs
tou$i~e, and help ussurc that noticc is actudly dclivcred to the padcnt.) Requiring the
rccbrd is warranted given its impurtancc in ensuring thc patients aclually rcccivc the
noilcc in time 10 consider their appeal rights. This assurance far outweighs any argumcnt
a hbspiral might raiw suggesiing that this is Loo burdcnsomt ;r requircmcnt.
8

CR[S should devise a standard to mcasure whethcr notices are delivered "as far in
adllmcc of discharge as possible." 42 C.F.R.
00 405.L205 (c)(l);422.620(cI(1). Such a
st2 jdard should requirc that the discharge notice ideally bc delivered to paticnrs no later
thqb the day prior to discharge or, i T specific. identifisd information is not availablc until
thc day of discharge, at Ic~srtivc hours prior to discharge. Thc standard should also
sp!'citically prohibit hospitals horn adopting a hlankct policy or delivering the notices on
the day of discharge.

Thank yoil for the opportunity to submit rhcsc commenLv on bchalf of our clien~s,
Vcry truly youla,

Diane F Puulson
Seniur Auomey

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efending Liberty
Pursuing Justice
AMERICAN BAR ~SSOC~ATION Governmental Affairs Ofice
7.40 Flfrccnth SlrM. NW
W~diingion,DC 2W05-1012
(202) 662.1 760
FAX. Q02)GG2-1762

May 5,2007

OMB Desk Oficu:OMB Human Resources and Housing Braich
Attention Carolyn Lovctt
New Executive Office
Building
R o o m 10235
Washington, DC 20503

Re: Important Message from Medicare, CMS-R-193(OMB#: 093-0692);
Detailed Noticc of Discharge, CMS- 10066 (OMB#:0938-New)
72 Fed. Res. 171 69 (April 6,2007)
Dear Sir or:Madam

The American Bar Association apprcciatcs thc opportunity to comment on the
lmporronf Messugefrom Mcdicare and Detailed Noticc of Discharge, published
in the Federal Register on Friday. April 6,2007, 72 Fed. Reg. 17169.
The ABA i s the world's largest volunlvy professional oryanization with more
than 400,000 members.The ABA has worked for many years lo slrmgthcn

procedural due proccss in Social Sccurity and Mcdicare, Our comments are
bascd on numaous palicics of the ABA that support cfforts to improvo thc
administrative and judicial process utilized by the Department of Health and
Human Semiccs (IJX)and the Social Security Administration (SSA). For
almost nvenry years, the ABA has advocated that Medicare beneficiaries are
entitled to due process throughout the Medicare detemlination and appeals
process. We have cansistmtly advocated ibr a simplified and orderIy
determination pmccss. including improvcmcnt of thc various noticcs givcn to
beneficiaries about hospital discharges to hospital patients.

Overall, the draft notices an clearer and more understandable than prevjous
versions. In pdcular, the description of discharge rights in the Important
Message is more prominent, concise and useful to patients. .The information
about patient liability pending appeals is morc cornprchcnsiblc. Howcvcr. wc
believe addilional improvcmcnts should be adopted.

DMB DEP DIP PICPIT

To make both notices morc rcadablc and user t'%endly,and to help patients bmefitfmm
the second notice and cnsurc timcly dcGvcry of it, we suggest the following revisions.

n

Make the Notices More User-friendly and Rcadahle
As we mentioned above, the notices are generalIy clear an.dunderstandable. To further
improve them, we rczornrnend the following:
In the Important Mmugc. bold the deadline for rcqucsting QIO review to call the

rcadcr's attention to this critical information;
In thc Imporrunt Mer.~uge,delete the bullet advising patients to contact 1-800
ME'DlCARE if they do not think they have sufficient time to appeal, for the
reasons mentioned above;
Require that hformatiou written into the DeraifcdNotice of Disc)iarge be legible.
Help Patients Benefit From tbe ImportantMessage Upon Discharge.
We are concerned that upon receiving the copy of rhe important Message prior to
discharge ("folJowup notice"), mauy patients will fail to read or usc it bccause they will
not realize that i t relates to their impmding discharge. To help paticnts bcncfir from the
follow up noticc, we suggest the following:

Change the title to include [he word, "discharge" (i.e., "An lmportanr Message
From Medicure aboul Yorcr Inpaierrt und Dirchrge Rights '9;
Inlnhc lint section lisling hospital inpatienr rights, add a bullet alerting persons
that they will r d v c a copy of the notice prior lo discharge; and
Requite hospitals and Mcdjcare Advantage plans to deliver the follow up noticc
and cxplain irs relevance when patients are told of their discharge.

Ensure Timely Delivery of the Second Irnpo~untMc~.urgeto Afford Paticnb the
Opportunity ta Exercise thekAppea1 Rights
Hospitals and plans must deliver the second Inportant Message "as far in advance of
disckgc as possible, but not more than 2 calendar days before discharge." 42 CFR 18
405.120s (c)(l); 422.620(c)(l). Bccausc thcrc is no deadline for delivering the follow
up notice, many patients could rcccive it mo late, after thcy havc lost any meaningful
opportunity to exercise their appeal rights. Notices will be uscless to paticnts if thcy are
delivered as they are packing to leave or being wheeled out the hospital door.
In the "Revisions to the Important Message from Medicare,"CMS indicates it addcd thc
bullct tclling persons to call 1-800-MEDICARE if (hey have insufficient time to consider
thcir rights. to address c o n c m s "that bcneliciaries may be @ven the nolice on their way
out of the hospital." Howcvcr, wc do not undustand how this information helps patients.
First, CMS has not indicated that 1-800-MEDICAREoperators have the authority to
e x h d the deadline for patients to filen QIO appeal. Second, even if 1-800-MEDICARE

MAY-07-2007

15:45

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operators havc the authority to intervene, 1-800-MEDICAREdocs not have the capacity
to respond quickly cnough.
To promote the timcly dclivery or [he follow-up notice, we suggest thc following:
Require that the parient's signamre, with date and time of dclivay, be obtained on
\he follow-up notice and that a copy is kept in thc patient's record. Thc
information could be recorded in the "Additional hformation" section This
rccord will allow CMS to monitor when the notices arc actually delivered and will
discourage hospitals &om delivering t h m too late. Xt will also hclp to assure that
notice is actually delivered to the patient. Requiring the maintcnancc of this
record is warranted yvcn its iniportance in ensuring the patients actually receive
the notice in time to considcr their appeal rights.

CMS should dtvisc a standard to measure whether noticcs are delivered "as far in
advance of discharge as possible." 42 CFR $6 405.1205 (c)(l); 422.620 (c)(l).
Such a standard should require that the dischargc notice be delivered to patients
on the day prior to dischargc or, if specific, identificd information is not available
until the day of discharge, at lcast five hours prior to discharga. The standard
should also specifically prohibit hospitals Cmm adopting a blanlcct policy of
delivering the notices on the day of discharge.
We thank you for the opportunity to submit these comments.

Denise A. Cardman
Acting Director

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202 395 6974
To: 2B2 395 6974

~ r l i w t i qbiupi&~r
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and rht~palunlsf l y &nu

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May 4,2007

Ms. Carolyn Lovett
OMB Desk Ot'f-icer
OMB 1-Juman Resources and Housing Branch
New Exccutiva OBiac Building, Room 10235
Washington,

DC 20503

Re: CMS-RJ93 (OMB#; 6938-11692)Proposed Revisfun oflmpnr/aar Messugc from
Medicare and Related Paperwork Rcqrruements pol. 72, No. 661,Aprll6,ZUOl
Dear Ms.Lovert:

On belulrof its 145 members, the MIchignn Health O &spitat Associaion npprecidtes the
opponunity to provide comments to the Centers for Medicare & Medicaid Services' (CMS)
regarding its proposed revision of the "lmpomt Message from Medicare" ([M)and related
paperwork rtquirernents, which wcrc submjned to the Office of Management and Budget
(OMB). The proposed IM would implement rhe revised regularions requiring hospitals to aorify
Mcdic;an beneficiariesabout &air llospihl discharge app~tllrights, which were published in the
November 27,2006 Federal Rcgisfer.

Thc MZM appreciates fhc extent to which h e CMS responded to many of thc prncticnl
problems identified in comhcnts submitted. While the ihnl zcgulation is marc manageable, it
continues lo pose n significant burden on hospitals that will offset my additional benefit that
beneficiaries might occroe. The M1.U is conctrncd that thc CMS will bo unable to ptovldc
hospitalr with thc finnl notice lungungc and inutruetionr to allow hospitrls sufficient timc to
cffectivcly implement the ncw requirements prlor to tbe July 1 implementation drrtc.
ADM&STRAT~VE BURDEN
NOR HOSPITALS
Currently, hospitals generally provide the IM to bcnckiciarics in thcir admissions packct.
Thc IM explains bencficiarics*rights to have thcir di~cbargcdecisions reviewed by the local
Quality lmprovemcnt Org~imtion(QTO) if they believe they arc being discharged too soon.
'lhe notice provides all o f the intonation beneficinrics need for requesting an appeal and
expl~insthat they will not be held tinancially liable for continued hospital care while the QIO
reviews their case. Hospitals provide a detailed notice with specitic reasons explaining why
hospital cure is no longer required when beneficiaries indicate ~hnkthey arc uncomfortable with
their plmlled discharge date.

(3MB DEP

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Undcr the new rtgi~It\lions,haspitala must provide the fh4 to bcnclici~csno lam th
days following drnis~on,~ o ~ ~ i ~ must
~ s tensure
a f f that beneficiaries undermnd thc notice
and sign a copy of it documenting when they rcuived it and lhar they understand i t FIospitnl
staff art also required to give beneficiaries a copy of the signed notice, as well 8s another copy of
the signed notice no more than two days prior to discharge. Hospital staff will be required to
provide a detailed notice with information about a pnrliculat discharge only when a beneficinry
requcsu n QTO review. We believe that focusing the process and beneficiary questions at the

beginning of the admission will help form more realistic bcneficiay txpectalions about hospital
adlnissions and improve their understanding of how decisions are made and how the dischtvge

planning process works.
Even with tl~cconservative burden eslimute included in the popework clearance pncknge,
the CMS projects that the annual burden will incrcuse From 208,333 hours to 3,250,000 horus - a
more than fifteen-fold increase. While admissions clerks provided ~ lformer
~ t noticc to
bcncficiaries, rhe revised process rcquirea someone with greater experrise to explain medical
nccessiry and the discharge plmnic~gprocess - genernl ly a nurse case manager or social wotker.
The nmtion~lavtragc hourly wage Ibr clerks is about $12.50, while rhc avcragc hourly wage for
nurses and social workers me signiCican\ly higher, r n ~ i n from
g $24.00-$28.00. Conservatively,
that incrc~scshospital hbor cost from opproximarcly $2.6 million to between $78 and $91
million. It is unclear whether this new rquircmenl is going to yield sufficient benefit to
Medicare beneficiaries to warrant the signifimnl cosr and adrninistrativc burden jncrense to
hospitals. As a result, the MllA recommends that OMB conditionrlly approve thc ncw form
and process and rtquirc that the CMS perform an cvalurtion o$er the first year to
dettrrnlnc whether the new procera ham yielded rufficlent benefit to warrant this significant
increme In ndminiatrrtCvc coste.

T m c . OF 'IMPLEMENTATION
It is our understending thet under the best-care scenario, the OMB-upproved nolice and
iflst~ction~
will not be availuble lo hospitals until late M a y or carly June. With the July 1
effective dnte quickly approhching, we are very concerned that hospitals will have insufficient
time Lo print the new notices, prepare written internal policies and innructions and train staff
prior to the July 1 effective d~tc. If less time is ovailahlc, we believe they will be unable to mcct
the July 1 date. Thc MHA urges the OMR te givc hospitals r minimum of 60 days before
thcy arc required to lmplerncnt tht: ncw rcquircmmts. h a result, it will be ncccesnry for
thc CMS ta delay the July 1 date.

ISSUES
R~qvrnmcC J ~ ~ I Q I C APRIOR
T ~ OTO
N IM~LEMPNTATION
Wc believe that [he list of issues needing clarification has grown from those previously
identified by the AHA md others. Ad a result, the mIA rccommenda that OM13 requlrc the
CMS to nddreas the following iv~uesand clrrrifications in it8 instructinns prior to rclca~ing
and implementing thc new noticc:

Provide slgnlficnnt lrtitudc to hospitals in how they provlde the notice ta beneficiary
represcntativcs if thc bcncficiry i g unnble to rectlvt o f undcntnnd thr noticc. Rle
AHA and others mired this issue during the comment period on \he proposed rule, and the
preomble discussion of the final rulc indicated thnt tlic CMS planned to provide guidmcc
regarding how hospitals and health plans may deliver the notice in cases where a

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beneficiary9srcpwntative may not be immediately available. However, the CMS failcblto
include such guidance in the inutruatjons for the first draft revised notice offered for
comment an January 5 or in thc second revised instructions submitted to the O m . In

Much, the AHA urged the CMS ro allow hospitals any means of commmication ntcessory'
to conduct the notice prooess with bcncficiary representatives (telcphane, fa,
emnil, etc.)
and allow record nota~ionswhen using these alternatives to in-person notice. Convcrsstions
with the CMS slaflsuggest that hospltols that follow their usual prorocols in dealing with
patient represcntilrives on officinl documents and forms t h ~ must
c
be signed will be in
compliance EW long ns they documenr their methods. Wc urgc the O I W to ensurc thnt the
CMS clarifies t h i ~issue In the fin01 inltructions.
YrovicIt flewlbllity on thc tlmlng of the first notice to accomrnodutc lutc Fricll~yand
Snturdvy wclmirriunu. Hospitds participating in a recent telcconfcrencc on implcrncntotion
issues cxpressed concern that they would bc unable to provide notices to palienu admitted oa
weekends when hospital case lnanngcrs and discharge planners are not workin8. Although
lhey are on call for immediale problems, it would be impractical to call them in to explain the
initid nolice, In divcussing wnys 10 address the problem, ~ w ooptions emerged. One is to
allow ~criptedregistrution staff to provide the initial notice and answer typical qucslions. In
cnve3 where the questions require discussion with a case mmagtr or dischar~cplnnner, the
CMS could allow follow up in the w l y part of the next work week. Anothet option is to
simply provide an cxrm day ro provide the initial notice. For example, hvo days is
insufficient for a Friday afternoon or evening admission because the second day after
admission is Suudsy. In the case of Suturday admissions, the second day aRer admission
would be Mondny, making worknow nearly impossible as workers are catching up with
weekend activi1.y and new admissions.
Providc romc flexibility for dcaignrting thc attending physicinn for emergency
sdmissionr. Far erner8ency admissions, many hospitals are planning to provide m d discuss
the noticc when they get bencficiaries' consents for treatment. I-lowever, the name of the
ntiending physician is oAen unknown at thnt time, and the rorm requires the name of the
atlcndiny physician to be inserted following the patient's name and ID number. We see two
options Tor solving this problem: I ) ullow designation ofthe allonding physicinn on the lorn1
d e r its rcceipl and signu~uretor emerjjency admissions, or 2) omit the designation of tlie
anending physician on tho tbrrn.

Allow provision nnd expInnation of tbt initid notice during prc-admisaioa t ~ t i n g
and
rcgistmtion Many of our hospita1.u would like to incorpotete the inilial notice into the preadmission process for elective admission~when bmetician'es Rrc focuscd on the regjstrction
process. This suggestion would clearly help bmciiciarits, but it is unclear whether the
rcgularions would allow il.
Provide on the CM9' Wcb site the text af tht notlcc tronrlnted Into the IS lnnguagcs
hn~pitalrfrcqucntly cncountcr. Almost 20 percent of'rhe U.S.population speaks a
language other than English at home, Hospitals u c required to provide Imgultge services ibr
patients with limited English proficiency, but they do not receive cornpensarion for the cost
of thosc services. Thc sizc of this population and the vest number of languages that hospital
staff cnoounter mnkc it very djfiScult for individual hospitmls to provide nnnslated

,

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documents. Since the rtxt oilhis notice cannot be altered by the hospital, the CMS s ou
obain and provide nanslations. Thc Social Security ~drni&stration'hasa list of 25
languagw that i t usas for such p ~ p O S t 9 .A recent survey by the Health Rcseruch and
Educ~tionalTrust identified 15 langun~csthat at least 20 percent of hospitals encounter
frequently: Spanish; Chincsq Victnmcse; Jnpmtse; Korean; Russian; German;French;
Arabic; Itolinn; Laotian; Hindi; Poli~h;Tagalog; and Thai.

111 conclusion, thc MU i s concerned due to ~ h increased
c
odminislrativc burden, staff
resources, and coat of this notice on hospitals. The clarifications wc htrve requnkd are essential
for hospirals to be able to cffkctively implement the new rules and notices, It is also vital that
hospitals have sufficient time to review theqc changes prior ro implementation. lf you hnve any
questions concerning our comments, please fetl free to contact me at (51 7) 703-8603or
[email protected].

Marilyn Litkn-Klein,Senior Director
Health Policy and Finance

MHY-87-2807

MAY. 'I. 'IUUI

15:4R

OMB DEP DIR MGMT

1 2 : 2 4 ~ A~H A I U l O l b S b l O
Liberty Place, Suilc 700
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Association

May 2,2007

Ms.Carolyn Lovett
OMB Desk Officer
OMB Human Resources and Housing Bmoh
New Executive Office Building,Room 10235
Washington, DC 20503
Re: CMS4-I93 (OMB#:0938-0692) Roposed Revision of Important Message from
Medicare and Related Pupcnuork Reqvirrments (YoL 72, No. 661, Aprl6,2007

Dear Ms.Lovett:
On behalf of o~u.nearly 5,000 member hospitals, health systems and otha health care
organizations, and our 37,000 individual members,the American Hospita Association (AHA)
appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services'
(CMS) proposed revision of the "Important Message from Medicare" 0 and its related
paperwork requirements,which were submitled to the Office of Management and Budget
(OMB).The proposed new IMwould implement the revised regulations requiring hospitals to
notify Medicare beneficiaries about their hospital discharse appeal rights, which were published
in the November 27,2006 FederalRegiJter,
The AHA appreciates the extent to which CMS responded to many of the practical problems
identified in our comments en the proposed rule. W e the final regulation is more workable, it
still would pose a sigificant burden on hospitals that may counter any additional betzefit that
beneficiaries might accrue. We are concerned that CMS will be unable to provide hospitals with
the final notice language and instructions with sufficien~time for hospitals to effectively
implement the new requirements by the regulation's July 1 implementation date.

A D ~ S T R A T WBURDEN
E
FOR ~~IOSPXTALS
Currently,hospitals generally provide the 1M to beneficiaries in their admissions package. The
IM explains beneficiaries' rights to have their discharge decisions reviewed by the Iocal Quality
Improvement Organization (QIO) if they believe they are being discharged too soon. The notice
provides a l l of the information beneficiaries need to request an appeal and explains that they will
not be held financially liable for continued hospital care while the QIO rewiews their case.

MAY-07-2007

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May 2,2007
Page 2 of 4

Hospitals pmvide a more detailed notice wib specific reasons explaining why hospital care is n8
longer required when beneficiaies indicate thal they are uncomfortablewith their planned
discharge date.

Under the new regulations, hospitals must provide the IM to bendciaries no later than W o days
following admission. Hospital staff must ensure that beneficiariesunderstand the notice and sign
a copy of it documenting when they received it and chrt they understand it. Then, hospital stdf
must give the beneficiaries a copy of the signed notice, as well u mothu a p y of the signed
notice no more than Wo days prior to discharge. Hospital staff will be required to give a detailed
notice with information about a particular discharge only when a beneficiary requests a QIO
review, We believe that focusing the process and beneficiary questions at the beginning of the
admission will help form more realistic beneficiary expectations about hospital admissions and
improve their understandtpg ofhow decisions are made and how the discharge planning process
works. However, it comes at a heavy price.
Even with the consexvative burden estimate included in the paperwork clearance package, CMS
projects that the annual burden will increase fiom 208,333 hours to 3,250,000 hours a more
than fifteen-fold increase. And, while admissions clerks provided the former notice to
bmeficiaries, the new process requires someone with the experlist to explain medical necessity
and the discharge planning process g e n d y a nurse case manager or social worker. The
nationai average hourly wage for clerks is about 512.50, while the averase hourly wage for
nurses and social wo&ers ranges h m SD.00-528.00. Consmatively, that talres the personnel
cost fiom about 82.6 million to between 578 and $91 million. h addition,hoqitals will need to
pn'nt thrte-part automatic copy fomrs for about 13 million admissions p a year and train staff in
the new requirements, resulting in total costs that will easily surpass 6100 million per year.
Furthermore,it is unclear whether tbis new requirmmt is going to yield sufficient benefit to
Medicare beneficiaries to warrant the significant cost and burdm increase to hospitals.
Therefore, the AHA recommend^ & i t OMB conditionally approve the new form and
process and require that CMS perform an evaluation aflm the frrst year to determine
whether the new process has yielded mfficnt benefit to warrant this significant increase
in administratfve costs.

-

-

Far too often, adminisuative requirements are adopted to address anticipated or perceived problems.
For example, Congress enacted discharge rightr requirements when the inpatient prospective
payment system (PPS) was m a d in response to widespread fears that hospitals would discharse
patients prematurely due to the incentives of the PPS to 3horten lea,?
of stay. Those fears of
"quick=, sickd' discharges were not realized. Also, m earlier requrement for beneficiaries to sign
for recdpt of rhe notice was found to be unnecessary and subsequently eliminated. In short, too
many health care dollars arc being devoted to abbhtrative and paperwork requirements.
Escalating health care costs and the rapid expansion of the Medicare beneficiary population
underscore that our countxy needs more of its health care dollars devoted to bed-side care not

-

papework.

-

MG
OF ~IPLEMERTATIoN
It Is our &erstanding &om CMS staff that under the best-case scenario, the OMB-approved

p. 13/18

Carolyn Lovctt
May 2,2007
Page 3 of 4

?tie

notice and instructions would not bt available to hospitals until late May or early June. Wi
July 1 effective date of the reguletions approaching, we arc concaned that hospitals will have
insufficient time to print thc new notices. prepare written intanal policies and instructions and
train staff prior to July 1. Ifeven less time is available, we believe they will be unable to meet
the July 1 date. And, if the approved notice and instructions are not available by July 1, we do
not h o w what instructions to give our members, since they cannot use a notice that OMB has ,
not approved. Consequently, the -A urges OME to give hospitals a minimum of 60 days
before they are req~iredto implement the new requiremenu.

ISSUB REQUIRING
C L A R ~ C A ~PRIOR
O N TO LMPLEMENTA~ON
As the AKA and state hospital associations have worked with hospitals on preirnplernentatim
planning, we realized that the list of issues needing clatificatian has grown fim those identified
in our March 6 l e m to CMS. The A S 4 recommends that OOMB require C M S to address the
following issues and clarifications in its instructions prior to releasing and implementing
the new notice:

Provide signiiicant lrtitnde to hospitals in how they provide the notice to bnreZiciary
represcntativcs if the beneficiary is -able to receive or anderstand the notice. The
AHA and others raised this issue during the comment period on the proposed rule, and the
preamble discussion of the h a 1rule indicated that CMS planned to provide guidance
regarding how hospitals aud health plans may deliver the notice in cases where a
beneficiary's representative may not be immediately available. However, CMS failed to
include such dance in the iPsfmdions for the fist draft revised notice offered for
oomment on January 5 or in the second revised instructions submitted to OMB. In March,
we urged CMS to allow hospitals any means of communication necessary to conduct the
notice process with beneficiary representatives (telephone, fgx, m a i l , etc.) and allow record
notations when using these alternatives to in-pason notice. Conversations with CMS staff
suggest that hospitals that follow their usual prorocols in dealing with patient representatives
on official documau and formsthat must be signed will be in compliance as long as they
document their methods. We urge OMB to ensure &at CMS clarifies this issue in the h a 1
instructions.

Provide some Oenibility on the timing of the first notice to accommodate late Friday and
Saturday adm5saions. Hospitals participating in a recent teleconference on implementation
issues expressed concern that they would be unable to provide notices to patients admitted on
weekends when hospital case managers and discharge plauners do not work Althou& they
are on call for immediate probletns, it would be impractical to call them in to explain the
initial notice. In discussing ways to address the problem, two options emerged. One is to
allow scripted registration staff to provide the initial notice and answer typical questions. In
cases where the questions require discussion with a case manager or digcharge planner, CMS
could allow for follow up in the earIy part ofthe next work week. Another option is to
simply provide an extra day to provide the initial notice. For example, two days is
insufficient fcrr a Friday aftmoon or evening admission because the second day after
admission is Sunday. In the case of Saturday admissions, the second day afta admission
would be Monday, making workflow nearly impossible as workers are catching up with
weekend activity and new admissions.

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Provide some fltniility for designating the attending phydcim for emergency
admissions. For emergency admissions, many hospitals are planning to provide and discuss
the notice when they get beneficiazies' consents for treatmart However, the name of the
attending physician is o h not known at that time,and the form requires the name of the
attending physician to be inserted following the patient's na& i
d IDnumber. We see two
options for solving this problem: 1) allow designation of the anendins physician on the form
after its receipt and signature for emergency admissions,or 2) omit the designation of the
attending physician an the form.
Allow provision and explanation of the hitid notice during preadmission testing and
registration. Many of our hospitals would like to incorporate the initial notice into the preadmissionprocess for elective admissions when beneficiaries am focused on the registration
process. This susgestion would clearly help beneficiaries, but it is unclear whether the
regulations would allow it.
* Provide on CMSgWeb site the text of the notice translated into the 15 languages

hospitals frequently enconnttr. U o s t onefifth of the U.S. population speaks a language
other than English at home. Hospitals are rqdred to provide language semices for patients
with limited English proficiency, but they do not receive campensation for the cost of those
services. T l e size of this population and the vast number of languages that hospital staff
encounter make it very difficult for individual hospitals to provide translated documents.
Since the text ofthis notice carmot be altered by the hospital, CMS should obtain and provide
bimslations. ?he Social Security Adxninistrstion bas a list of 15 languages that it uses for
such purposes. Last year, the AHA'S research affiliate, the Health Research and Educational
T w conducted a survey of hospital language services that identified 15 languages that at
least 20 percent of hospitals encounter fi-equcntly:Spanish;Chinese; Vietnamese; Japanese;
Korew Russian; Gcnnan; French; Arabic; Italian; Lao*
Hindi;PoZish; Tagalog, and
Thai
In conclusion, this new process adds significant time and cost for hospitals. The clarifications
effectively implement the new rules
and notices.
we have requested are essential for hospitals to be able to

If you any have questions concerning our comments, please feel free to contact me or Ellen
Pryga, AHA director for policy, at (202) 626-2267 or mrvea@alsa~.

gkQ~~
'C

Pollack

~xechtiveVice Presideat

Cc:Bonnie Harkless (CMS)