Comments 11-44

--,&--

May 3,2007

OMB Human Resources 8 Housing Branch
ATTN: Carolyn Lovett

-

-'IC-*-

Bn'dg&
1kRr 300
1918 WcR boyad D
M Audn.TX7873V-5036
Phone 512-329-661 0 h 512-327-7159 *lulw.unt

New Executive Oftice Building Room 10235
Washington DC 20503

Re: Important Message from Medi-e (IM) (CMS-R-193) a m i a t e d with CMS4105-F, the final
rule fbr notification of hospital discharge appeal rights.
Ms. Lovett
TMF Health Quality Institute (TMF) is the quality irnprwement organization (QIO) authorized by
the Medicam program to review Inpatient services prwlded to Medlcare paUents in the state of
Mediire cases to determine if the services meet medically acceptabie
Texas. By law, we re*
standards of care, arc medically necessary, and are delivered in the most appropriate setting.
Staff members hwe at TMF, involved in the appeals processes, have reviewed the Important
Message from Medlcare (IM) (CMS-R-193) assodated wlm CMS-LSIOSF, the final rule for
notfiation of hospital dhcharge appeal rights. We m m m e n d that the IM (CMS-R-103) be
modified to indude the name and provider number of the facility in whlch the patlent Is adrnlaed.
Speclflcally, the 1M should lndude the name and the provider number that the kcility use5 for
billing with Medicare. This will save &able time when the patient aontacts me QIO for appeal.
Patients in appeal altuatlons am frequently anxlous and may be confused about the name of the
facility, especially one that is a part of a large system, w tM hss had frequent name changes.
Although thffe Is a contad name and number farme facility on the IM, it would simplify the w r l c
of the QIO to have thls deflnlte Idenwng Information at the beglnnlng of the process

Thank you,

&&vp.i*
Janis B m n l RN CPHQ
Phone: 51 2-334-1667
FBX:1800-725-8245

Tucson, AZ 85724-51 62
Office: 520-694-2729
Fax 520-694-201 4
ernail: msisson@umcaz,edu
CONFIDENTIALITY NOTICE:
This message and any included attachments are from University Medical Center
Corporation and are intended only for the addressee. The information contained
in this message is confidential and may constitute inside or non-public
information under internafional, federal, or state laws and is intended only for the
use of the addressee. Unauthorized forwarding, copying, printing, distributing, or
using such information is strictly prohibited and may be unlawful. If you are not
the addressee, please promptly delete this message and notify the sender of the
delivery error by e-mail or you may call University Medical Center in Tucson,
Arizona, USA at (520) 694-641 7

The implementation of Hospital Discharge Appeal Notices wll require extensive
resources and coordinatron. We recommend that i t be carefully considered
whether the first notice to the patient should include the Hospital Discharge
Appeal R~ghts.We have been working for two years on a formalized process
where we schedule a discharge one day in advance. We have implemented
many strategies to improve this, including a formal patient Row consulting
engagement with a highly-rated consulbng group. Even with their assistance, we
have been able to gain only a 3 5 % accuracy in predicting discharges 1 day in
advance. This is due to issues such as placement of patients in a SNF,waiting
for test results, complicated cases, patient's condition changes, etc. Please
consider these as questions and comments submitted regarding the Detailed
Notice of Discharye and Hospital Discharge Appeal Rights.

1.
Werecommendthataspeadclimitbesetastothenumberoftimesa
patient can appeallrefuse to dlc.
2.
How All MlC want the days billed to them during the appeal process. Will
they'want these charges under non-covered?
3.
Will there be some type of indicator established for the UB form that shows
the discharge notice was issued to the pt?
4.
Process seems designed to encourage pahents to appeal. Please re-script
instructions so that patients understand that this is an option, not an expectation.
5.
Please extended the deadline to p r w ~ d esufficient time to prepare
(changes to forms, computer systems, process design, education)
6.
The first notice is part of the process. However, the second notice places a
huge burden on the hospital and requires added resources. We recommend
one notice upon admission.
Please allow for the first notice to be delivered and signcd dunng pre7.
admission.
Please provide more specific information and instructions on who the QIO
8.
is gang to notify at the hosp~talof their review results.
Also, please provide specific instructions on what happens ~fthe patient
9.
calls the QIO and does not inform the hospital staff that an appeal has been
subm~tted.
10. Please prwide more direction on any specific requirements on the form
e.g., Does font need to be a 12 as is used in the DRAFT notice from CMS?
11 .
On the Detailed Notice of Discharge, the process can be simplified by
establishing the Patient ID as the hospital's encounter number.

Thank you

Marjorie Sisson, Director
Director, Transition Management
University Medical Center
P.O. Box 2451 62

Tucson, AZ 85724-51 62
Office: 520-694-2729
Fax: 520-694-201 4
em ail: [email protected]
CONFI DENTIALITY NOTICE:
Thts message and any included attachments are from University Medical Center
Corporation and are intended only for the addressee. The information contained
in this message is confidential and may constitute inside or non-public
information under international, federal, or state laws and is intended only for the
use of the addressee. Unauthon'zed forwarding, copying, printing, distributing, or
using such information i s strictly prohibited and may be unlawful. I f you are not
the addressee, please promptly delete this message and notify the sender of the
delivery error by e-mail or you may call University Medical Center in Tucson,
Arizona, USA at (520) 694-641 7.

.MAY-09-2007
---

15:59

U..

DrlB/CI I RFI

282 395 5167

The implementation of Hospital Discharge Appeal Notices urill require extensive
resources and coordinabon. We recommend that i t be carefully consdered
whether the first notice to the patient should include the Hospital Discharge
Appeal Rights. We have been working for two years on a formalized process
where we schedule a discharge one day in advance. We have implemented
many strategies to improve this, including a formal patient flow consulting
engagement with a highly-rated consulting group. Even with their assistance, we
have been able to gain only a 350h accuracy in pred~ctingdischarges 7 day in
advance. This is due to issues such as placement of patients in a SNF, waiting
for test results, complicated cases, patient's condition changes, etc. Please
consider these as questions and comments submitted regarding the Detailed
Notice of Discharge and Hospital Discharge Appeal Rights.

We recommend that a speatic limit be set as to the number of times a
patient can appealJrefuse to dlc.
How inill M/C want the days billed to them during the appeal process. Will
2.
they want these charges under non-covered?
Will there be some type of indicator established for the UB f o m that shows
3.
the discharge notice was issued to the pt?
Process seems designed to encourage patients to appeal. Please re-script
4.
instructions so that patients understand that this is an option, not an expectation.
Please extended the deadline to prwide sufficient time to prepare
5.
(changes to forms, computer systems, process design, education)
6.
The first notice i s part of the process. However, the second notice places a
huge burden on the hospital and requires added resources. We recommend
one notice upon admission.
7.
Please allow for the first notice to be delivered and signed during preadmission.
8. Please provide more specific information and instructions on who the QIO
is going to notify at the hospital of their review results.
9.
Aiso, please provide specific instructions on what happens if the patient
calls the QIO and does not inform the hospital staff that an appeal has been
submitted.
10. Please prwide more direction on any specific requirements on the form
e.y., Does font need to be a 12 as is used in the DRAFT notice from CMS?
1 1 . On the Detailed Notice of Discharge, the process can be simplified by
establishing the Patient ID as the hospital's encounter number.
1.

Thank you.

M arjon'e Sisson, Director
Director, Transihon Management
University Medical Center
P.O. Box 2451 62

P.85/1R

-LION
New River Valley
Medical Center

Date:

May 2, 2007

To:

The Centers for Medicare and Medicaid S e ~ c e s

From: Clinical Effectiveness Deparrment of Canlion New River Valley Medical Center
Christiansburg, VA 24073

Re:

Comments regardug '7mportant Message h m M c d W and 'Detailed Notice of Dkbarge"

Hospital leaders agree that patiem and their families bavc tbe right to know about their dischrge apped
nghts. The difficulty for us lies in the actual carrying out of the jxocess as Medicare has oufIincdit. Our
concerns are as FoDaws:

1.
How do we accuratelypin-point when a patient is being discharged? TIe Medicare populationby
definition k tirher disabled or 65 and ova. Their hrdthcarl count, in the hospbl, is not always
predictable. For many of them their hospital stay goes earn day-to-day...especially ifthey are wiring for
a uuning home bed. It would be a terrific burdrn on bspihl mources to reneatea issue the lM in order
to make sure the patient receives it within 2 days of dudurge.

2.
WGdo provide m e management weekend covcragc, but it is for patient care h e s , certainly not
at thc level requued to provide b e second Important Messages fiom Medmrc AND thc Dchilrd Noticca

of Dischaxgc (if the paticnt appcals the discbarge decision). To m a the requhnenu of this ruling, I
foresee a tcmfic -in to aur system, both depvhnentaUy and organizadonally.
3.
Our facility has limited capacity. Dclay in discharge for two days, while an appeal is reviewed,
will h a c r our abiliry to provide care to thore who have greater needs. Our projection is b a t our
psychiatric care unit wid be housing paticats that should baw been discharged, but have appealed.
Currently thc Commonwealth of Vugiaia has limited psychatric ficilities. Our b g e n c y Departmrnk
bavc held patients waiting for a psychiaeic bed for up to four days. Does the right of the discharged patiat
exceed thc right of those seriously ill paticnts scckiag cue? Also keep in mind that our hospital is
reimbursed for inpatient psychiatric patients under the prospective payment system which could resuk in
increased Medicare costs.
As a compromise we feel it would be appropriate KOrequire the initial admission I
Mto be &livered and
signcd for, but the second IM before discharge has prumted iuelfas an unnecessary waste ofm a c e s
and a bothu to our patients and their famiha in timt of illness.

GC Duck, Manager ClinicaI Effectivcnes

CNRVMC

-- ., .. =

2900 Tyler Road Chrisrioruburg. Virginia 24073
.*

.

-JC.--l

lI:.;n.

? A 141M95

Phone 2d0731.2000

DETAILIED SOTICE OF DISCHARGE

This notice gives V ~ L ilI drtailzcl explanarion of why yczur hospital and dacror (and/or your
rliandgcd crrrc plan. it' I O U bclorrg to o ~ i ebclicvc
)
your hospital sewices shaul~lend on
-.--..., basect on Medicarc covc~.agcpolicies and medical
judLm:c.nt. A?%II\ Comment: Ili'r.ccoi,r,,le~~d
thar 11li.r ,se,ltcrrccdshrilrld 1-=all; "Btlsrd o , ~
i!feclictrr.c~c o ~ ~ e i . c ~ ~ ~ ? , ,c~nd
u l i irt
c i IIILL
c ~ ~IIICC/;C.U/ j i t ( [ q t c ~ l t r~ / ' I : o I I I . & c : I o ~ . ii'i~li~~~recvtic)tr
o[dtg
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tr
c.cr/-c&I!: .if~~g.b<:~ur~+ip.r~
O I I ~ 111u[,.o~to
)
Iu~tyc'i-need ru bc i ! f i ~ :
h f > . S ~''g ,
-

.

This is (lor all ~IfIicictl:Vfediccrr-erkci.sion. The decision on you!. nppc-1will come from your
Quality I~i~prortrnunt
Ol-~anizatio~?
(010).A C N A Comment:l.'l~~crsi~
rtclcl N c!~rr.!lifr.O ~ II~ ' ~ I LIN I
Of0 is. 771is\r~ocrllbc l~c/~?fiil
trs j,aric~,r.y I . \ . ~ J I ' / k11olr.i.\:lrctrir is ( 1 1 1 8 ~ h kospirtil
c
src![f'~r.ill
rrcocl ( I
hrrclf'.vfc~~ldnr+d~:ccl
c..v/~l~r~r~rrio~i
fur rhc pcrticrif.

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I . The facts: uscd to nlakc rhis dccislon: -4C3IA Conimcot: I4'c r.~c-o~nnrctrd
(o.111 *fi.rc-ls
' Bc chu~r,vcdto i ) ? f o ~ - ~ ) l ~
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~ cltrrcvrt clii~icnlcoildifiot~.ICe S I I ~ ~ Cfl~c>
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I - .-- ondphi~.ricietr(s~~cIic~~c
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clra i-cg&p I e n ~ ~II~LJ
c hospircr/
hosed nrr r l r c . n ~ g c f ! : -clin~cnl
q ; ~ ~ ~ C~U~I I ~ ~ I I Ius
~ I~~I . c - Y c c ~ L - this
~ I ~scctio~?:

1. Explanation of Medicare coverage policics that we used to dcfcnninc that Medicarc
longer C
111.0 /)uil/ls
~ v i l !no

hospital stilv' X C N A Comment : lye /c.-or.ontrncndrhc fOllo~r.i~ig

O V \~~ C I ~ I I .

a ) '/'11arIrospi~rrlsDc crllo~c!t~l
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.so rhur ~~pci-cirronc~l!~~
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/ra
choicc(.t.) cr11di ) ~ ~ i ~\sith
l r crflcliriorlkl
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notcs. I1.c helic\*c rlris ~r~otrld
critslrr-c rhnr 111c
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3 If'apl~lic;~ble.Mrdicarc mallazcd Citrc: policies. ~rot'isi~rns.
or r;ltic)n;llcused to ~naltc
this decision: c\CMA Con~mcnt:
:I/'~lrc
~-ecuntn~cncln~iu~
u(r/li)~cd
ill 6) abo\r IS ncluptc~c/.t1lri.v
serifczrtcc.yl~oi~/d
be rle1crcd.

If you \\lnuld like n copy of the Medicilre coverage policics or Medicare managed ca-c plan
policics used to lirake this dc-cision, or a copy of tllc docun-icnts sent to tl-te QJO.plcasc call us at
t i1lscl.r hosrital and/or plan telephone nu~nbcr;. ACbIA Comment: I.Ve reconarncmf Illat rlrc
p(iticvi1 h~ gi\le~l ~lrepl~orrc17 ~~11r.bcr,f6r
lifedicnrc ( I - POO-&~ED?C,DI
RE (I -800-633-4227)ui,(//ot.
1h1.1pllrrr ,/lrtllAei: L I I I ~!lo/ IIIC plror~e~lrrnrbci.of'rllc /IOJ,/I~IU/.
The Adiv/icu~-c.Cb~:c~).r/gc~
po1r~icj.sut.c
.sell/ fo J~/c:clic:o~.c~
Lclrgficiur.ic~.x,UI-cb u\a~lohlcorr rhc ~rcb,o ~ uclot
l Dc disclwsecl I)? culli/~gr11e
I
/ I i . I I C I I ~the
I Ipnrictrf
~
call fltr kos/)ttcil UIJOLII co1,cragc palicirs ptri.s 111e ~ U I . C / C ' I I
on 111cl~o.\./)irnl.1 ~,l~c/.c~ci.r
I hc c~.~~)la~inrrorr
qf .kleJicnrc* politics h\: ( I pluir 1.y nppr-oyl-iorc.

REGIONAL H O S P I T A L
710 South 13th
fllachw~ll,OK 71631-3706

(5301 36-3-2311

Rex Van Meter
Chlel Ezecutive Officer

May 3.2007

OMB Human Resoirrces and Housing Branch
Attention: Carolyn h v e t t
New Exccutive OTfice Bullding;
Room 10235

Washington, DC 20503
Dcar Ms.I ~ v e t t :
As previously requested, wc would like to rake this opportuni~yto c x p ~ s our
s concern

wirll thc proposed CMS-4105-1:
~ l regarding
e
Notification of Hospital Discharge Appeal
Rishcs. While we do not have an issuc with providing a revised 1M to Lhe patient ar the
time o ladlnission and discluye, we foe1 that Lhc proposed prohibition to provide his
document on thc day or discltargc provides an added administra~iveburden lo our facility.
Wc do concur that patients should have [he right to appeal their discharge but also believe
that tllc patient or hisher representative should bcar the responsibiliry without placing
addcd burden on thc facility.

While rhc proposed rulc states that ~ h patienthcneficiary
c
is not required to verify that the
notice was given it does rcquh-e the facility to be ~ b l uc, docurncnc hat the nolice has
hccn clclivered. Again we fccl that this requirement provides addcd administrative burdcn
on uur faci 1ity .
Wc would request lhat you review these conzments and reconsider implemrnting rlris rule
prior to July I , 2007.Thank you for your consideration.

4 u&-

Sjnc

Rex Van Me~er
Yrcsident
INTEGRIS Blackwell Regional I-Iospiral

I N T E G R I S
Gknfn

May 3,3007

OMB Hman Resources and Housing Branch
~ttention:Carolyn h v e a
New Execurive Oflice Building
Room 10235
Washington, DC 20505

Dear Ms.Lovat:
As previously requested, we would like to takc

this opportunity to express our conam
with the proposed CMS-4105-F rulc regarding Notificadon of 'I-Xospital Dschar~eAppeal
Rights. While we do not have an issue wirh providing a revised I
M to the patient at the
timc of admission and discharge, wc fwl that the proposed prohbiuon to provide this
documcar on rhe day of discharse provides an added administrative burden to our facility.
We do concur that patients should have the ri@t to appeal their dischaze but also bdicve
that the paticnt or hisher represmtativt: should bcar lfic responsibility without placing
added burdm on rhc ficility.

while the proposed rule statcs that the patient/beneficiary is not required to verify chat the
notice was given it does requirc thc faciliry to be able to document that the notice has been
delivered. Again we feel that this requirement provides added adminisnative burdm on our
Eacilicy.
We would request that you review t h s c comments and reconsider implcrnenting this rule
prior ro July 1,2007. Thank you for your consideration.

fqyJ

Jqy D.Jones, FACHE

Medical Center
960 Avent Drive m Grenada Mississippi 36901 -5094

Phone (662) 327-7000

May 4.2007
O M Human Resources and I-lousingBranch

Artenfion: Carolyn tovert
New Executive Ot5ce Building, Room 10235
Wmhington. DC 20503

Subject: CMS Proposed Revision of b11porru7t Messagc from Medicare and Related Paperwork
Requiremenrs (Vol. 72. No. 3). Januaq 5.2007

Dear Ms.Love~t:

I am uiriting to comment on ~11eCenters for Medicare & Medicaid Smites' (CMS) proposcd
revision of the "fmportan~Message from Medicare'' (IM) and iu related paperwork requirernenu
as submiued to the Offict of Management and Budget. This tcvision seeks to implement: he
revised regulations on notification of Medicare beneficiaries =garding their hospiul discharge
appeal rights, which were published on Novembcr 27,2006 in the Federal Re8i~rcr.While the
revision addresse3 many of the practical problems idenrified during the first comment period.
here continuos to be many issues lhar were not addressed. Dtspi~erhe revisions, his
rcquiremenr continues to represent a significant burden on l ~ o s p i ~ lespecially
s,
rural hospitals.
JJlo burden is dirtcrly related to the timing of rile notice. Ar adl1rissior.r or even shonly thereafter
ii is nearly impossible ro accurarely predict a discharge dare. In addhion, at the poin~during thc
stay and prior to discharge rhar the discharge date can be accurs~elyidentificd, the sraff needed to
accuralely administer and explain the lcrrer and process may 1101be available. This person.
generally a nurse case manager or social worker, must have rh? abiliry to explain medical
necessiry and h e discharge p l m i n g process. These s~affmembers require vast education and
higher salaries. In addiuon. utilizing nurses to administer ~1.lisprocess takes rime and resources
away from patient care ar a rime when nurses are already difficult to recruir and rerain.
The process for administering the lener when the paricnt is nor comperent is unachievable. A
significanrnumber oT elderly patients arc adrniwd without a Fdmily member or oiher decisionmaker. These individuals do not have fax machines, emnil. and orher high-tcch equipmen1 to
facilirarc rhe signing and education of tl~cfom~.especially it' rhe form inust be updarcd
frequently. Even ~elcphoncconsent is difficuir in this cssrs and in-person signing is irnpossiblc.

-2-

May 4,2007

This process must be flexible enough to allow for ihcse siiuations and for situations where no
dccision-maker exisrs.

The process can be implemented effectively, efficiently. and accurarely by focusing rhz proccss
and beneficiary questions on the front-end of the admission. Cllanging rhe process Lz his way
will sull allow realistic beneficiary expec~ationsaboul hospi~~l
sdmissions by improving
understanding of how decisions are rnadc and how tl-le discharge planning process works. This

education could be reinforced at discharge with discharge im~ructions.

Last. consideration must be given for the majority of parienrs. who despite carehl and extensive
explana~ionbecome h f u I and anxious ax a dme when undue mess is detrimen~alto heir
physical healrh and healing. Patienu, for rhe mosz part, do nor urlderstsnd "medically necessary"
or admission criteria, bur inslead want care provided coilsisrcnr with perceived need. Inaddiuon,
they do not understand ru, -:expectes' 01. "estimated" date of discharge and feel they are being
forced our of the hospital. Soine of these patients are so feari~11
rhar they will be held financially
responsible that thcy will elzcl to be discharged at the point ul'rhe lener. CMS nlust bear some
of rhe burden for proacrive. pre-admission education of expec~a~ions
and coverage.
Sincerely,

/kL. ''

Denton
Chief ~ x e c u t i vOfficer
e

Ch

s

ip"

'0

Medical Center
960 Avent Drive Grenada, Mississippi 28901-5094
Phone (662) 227-7000

OMB Human Resources and Housing Branch
Anendon: Carolyn Loven
New Execurive Oflice Building. Room 10255
Washingon, DC 3,050;
Subject: CMS Proposed Revision of Imponant Message &on1 Medicare and Relared Paperwork
Requirements (Vol. 72. No. 3), January 5.2007
Dear Ms. Lovea:

1 am wiring to comment on rhc Centers for Medicare & Medicaid Smices' (CMS)proposed
revision of the "Imporrant Message fiom Medicare" (IM) and irs relared paperwork requiremenrs
as submirted to b e Office of Managerneni and Budget. This revision seeks to implement h e
revised regulations on noufica~ionolMcdicnre beneficiaries regarding their hospital discharge
appeal rights, which were published on November 27, 2006 in the Federal Register. Wile the
revision addresses many of h e prac~icalproblems idenfified during the first comment period,
there conrinu~sto be many issues uhar were not addressed. Despire the revisions, this
requirement conti~~ues
ro represent a significant burden on hospirals, especially rural hospitals.
The bwdcn is directly relaled to the timing of rhe nolice. At admission or even shortly d~ereaher
ir is nearly impossible to accurarely predict a discharge dare. In addirion, ar the point during rhe
sray and prior ro discharge rhat the dischrge dare can be accurarc.ly identified. the slaff needed to
accurately administer and explain the lelter and process may noL be available. This person,
generally a nurse case manager or social worker, m u r have the. ability to explain medical
necessiry and the discharge planning procsss. These s~affmembers rcquire vasr educa~ionand
higher salaries. Tn addition urilizing nurses ro adminiszer this process takes ~ i m cand resources
away from pa~ienrcare at a limc when nurses are already difficull to recruit aid retain.
The process for adminisrcring rhe lelter when the pa~ientis no\ compemi is umchievable. A
significant number of elderly parienrs are admined withou~a Cmily mcrnber or orhsr decisionmaker. These individuals do not have fax machines, email, and orher high-rcch equipment to
facilitate rhe signing and edt~carionof the form. especially if rhe form must be updared
fkquently. Even telephone consent is difficult in this cases imd in-pets011 signing i s impossible.

-

-3-

May 4,2007

This process must be flexible enough to allow for rhese s i t d o n s slnd for sinrarioa where no
decision-maker exisfs.

The process can be implemented eRectively, erficiendy, and acc~uarelyby focusing the process
and beneficiary questions on the from-end of rhe admission. Changing the process in rhis way
mill srill allow realistic beneficiaty expecta~ionsabout hospiul admissions by improving
understai-rdingof how decisions are made and how the disclurgc p l a n i n g process works. T ~ i s
cducation could bc reinforced at discharge with discharge insrructions.
Last, consideration must be given for rhe inajority of patients. who despite carefill and extensive
explanation become fearful and anxious ar a rime when undue stress is detrimenral to their
physical health and healing. Patient..., Eor rhe lnosr pan, do nl)l undcrsrand "medically nccessary"
or admission criteria, but instead want care provided consincar wirl-r perceived need. In addi~ion,
they do nor undersrand an --e.upccred"or "estimated" dare of discharge and feel they are being
rorced o u of
~ the hospi~d.Some of hesc patients are so fearful ~ l ~hey
a r will be held financialiy
responsible thal they will elect lo be discharged at the poinr al'lht lener. CMS musl bear some
of rl~cburden Ibr proactive. prc-admission education of expec~a~ions
and coverage.

~ d h L@=CL.
y
RN, MSN, CPHQ
Chief Nursing Ofiicer

Kimberly W. Daniel

Ext 420
Email: [email protected]

May 4,2007

VIA FACSIMILE (202-395-6974) AND U.S. MAIL
OMB Human Resources and Housing Branch
Attention: Carolyn Lovett
New Executive Ofice Building
Room 10235
Washington, D.C. 20503
Re: Comment to Final Rule CMS41OS-F

Dear Ms. Lovett:
I am writing to you on behalf of MediCorp Health System ("MediCorp"),
located in Fredericksburg, Virginia. MediCorp is a not-for-profit regional health system,
comprised of twenty-eight health care facilities and wellness senrices. After reviewing
Final Rule CMS-4105-F, published in the Federal Register on November 27,2006,
MediCorp is concerned about the impact certain aspects of this Rule might have on it
and other similar health systems.

Specifically, MediCorpls concerns center on the requirement that, at
discharge, patients be s h w n a copy of the IM notice they signed upon admission.
MediCorp feels this is an unnecessarily cumbersome requirement MediCorp has
developed standardized admission and discharge processes to ensure patients receive
all required and helpful information and documentation. The Rule will require MediCorp
to take part of the admission packet/documentation and to add it to the discharge
information packet. Requiring the tracking and transfer of the original signed notice so it
is available at discharge as required creates a significant burden and does not seem to
improve the care or information provided to the patient. Giving the patient a copy of the
IM notice or another original JM notice would be equally effective and much less difficult
to accomplish.
As an alternative, MediCorp suggests that providers be given the option to
provide the first IM notice to the patient within a specified time period, and give the
patient a second IM notice form upon discharge. The result of this practice would be
that two signed IM notice forms would be included in the patient's medical record, rather
than one. The patient would receive the same information under this practice as he
would under the system set forth in the Final Rule, but providers would be relieved of
the additional burden of accessing the original signed form at discharge.

U ~ U C O C K DANIEL.
.
JOHNSON

8 NAGLE, P.C.

I N T E G R I S
ZoJa Zapli~l

MA FACSIMILE 202-395-6974
May 3,2007

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

Dear Ms.Lovett:
As previously requested, we would like to take this opportunity to express our ccmcem
with the proposed CMS-4105-F rule regarding Notification of Hospital Discharge Appeal
hghts. While N E G R I S Bass Baptist Health Center does not have an issue with
providing a revised IM ro the patient at the time of admission and discharge, we fee1 that
the proposed prohibition to provide this document on the day of discharge provides an
added administrative burden to our facility. We do concur that paticnts should have the
right to iippeal their discharge bur also believe that the patient or hidher representative
should bear the responsibility without placing added burden on the facility.

While thc proposed rule states that the patientheneficiary is not required to verify that the
notice was given it does require the facility to be able to document that the notice has
been delivered. Again we feel that this requirement provides added admhism!ive
burden OD our facility..
We would request that you review these comments and reoonsider implementing this rule
prior to July I , 2007.Thank you for your consideration.

~ e f &S.
e Tanant,
~
FACHE
President

6
9
ckhar1es Hospital
Questions regarding the new Importaut Message from Medicare
We are a general hospital with an attached acute rehabilitation Eacitity. When a patient is
discharged from the gmeml hospital and admitted to the rehab facility can we have the
patient date and sign the IM on dischaze and make a photocopy of it for our admission
notification upon admission to our rehab facility to be placed on that chart7

Thank you for your anticipated answers to these concerns.
Susan Heint, RN
Director, Care Management
St. Charles Hospital
200 Belle Tene Rd
Port Jefferson, NY 11777
Phone: 63 1 474-6877
Fax: 631 476-555 1
Emai2:wan. [email protected]

Saint Jose~h'sliosuital
@o*torcd

Sirrcrs of rhe J'urta&l

/?\

Mrtihr

April 30,2007

OMB Human Resources and Housing Rrmch
Attention: Carolyn Lovctl
New Exrcutivc Oflice Building
Room 10235
Washingron. DC 20503
FAX Number: 202->95-6974

HE: CMS-R-193
To Whom It May Conccm:

'1'F.zlollowir~gcomments are submitted by Saint Joscph's Nospital. a 504-bed hospital
located in Marsl=llield,Wisconsin. Thesc commcnts are in response lo thc request for
Eurthcr comments on the Detailed Notice of Discharge a5 pubIished in the April 6,2007
Federal Re,oi.vlcr. If you have any questions or cunccms, please call any uf thc contacrs
listsd at thc end of this lcttcr.
Again Saini Joscph's IIospital (SJH)undcrslands and thanks CMS 1br their ellbrts in
trying to makc sure thc Medicarc beneficiary is wet1 informed of their rights. Thc
changes rmdc in the final rulc (as published in the Fedrut Re,oiier on November 27,
2006) did help with some of the administrative burdens wc would have othcmise had to
Although some of thc burdcn has bccn lifted, SJH still feels that a couple rules if lifted
would not af7'el-t thc level of informalion thc patient receives. Wc agree thal the
Lmportant Message liom Medicare should be @vcn to the paticnt upon admission and
signed by rlle patient as recognition of inl'ormation givcn. Wc agree thd the patient
should receivc a copy of lhis also. We do. however, fee1 that ilis unnecessary for stal'f to
give a copy of (hat same signed document to [he pafient prior to discharge.
If the paticnl has rcceivcd a copy at thc h e w i n g of the stay, the duiplicilte copy would
bc repeating a task alrcady pcrfonned by hospi~alstafl: After many meetings regarding
this subjea since thc November 27* rule w z published, it was fclt hat nursing would be
the staff LO give thc last copy of this document hcre at SIH. This was due to thc Iugc
Wberc crring mmkcs the connccdonN
6 11 Saint Joseph Avmue, M a r ~ ~ c l W
d ,I 54449-1XY1 ? 15-367- 1715 ~ . ~ ~ j u ~ c p h s m . ~ ~ c l d o r g

MAY-09-2007
mey. +. ~ v v r

15:52
L . J > .

..

SJH Comments to OMB
l)fschrrge N~tiIicntion

numbcr of Medicare discharges daily compared to thc Case Management staffratio to
patients.

Nuniny is not wcll versed in Mcdicare regularions, so would not be able to answer
questions completely in most caqes. This would then involvc getting our Casc Managers
involved to explain any unclear items for the Medicrue bcneficiaiies. We feel that this
second explanation would be very time consuming and again taking the Nurse and the
Casc Manager awsy from other work needing to be completed.

If the notice must be again givcn before discharge, SJH would like to offer a difi2rent
option. Instead o t' giving thc patient a copy of the original signed Important Message
from Mcdicare, could thc Medicare beneficiary receive another unsigned 1M. We will
have the original signed IM as a pm of the M e d i d Rccords, but making s u e that the
signed version is used by the nurse during the discharge process could be a problem. SJH
would like to suggest that facilities be able to use new, unsigned Important Mcssage (om
Medicare forms so thatthcy could be placcd in the discharge packet up front and thus
would not be forgotten during the lengthy and educational discharge proccss. Nusing
gives many f o m and eduration during this time. so having a new IM form would bc the
easiest way to make sure the Medicare Beneficiary is properly informed. To pull another
form our of the chart in addition to the discharge packet would make it more of a chance
that it would be missed.

In closing, we ask that changes still uke place to make this less of an adminisaarive
burden for hospitals and be what it was intended to be -a rime for the Medicare
Beneficiazy to receive the information they nccd to make an educated decision about their
healthcare.
Sincerely yours.
Saint Joseph's Hosuital
And rep~esentativesof Saint Joseph's Hospital submitting these comments:

Sharon Kostroski
Vice Presidcnt of Quality & Safety
715-387-7220

Tammy Pawlicki
Manager of Casc Management
71 5-387-7152

Julie Rod&
Revenue CycldReimbursement Coordinator
715-337-7164

Medical Center
Phone (662) 227-7000

May 4,2007

OMB Human Resources and Housing Branch
Aaemion: Carolyn Lovet1
New Executive Ofice Building. Room 10235
Wasl~ingmn,DC 20503
Subject: CMS Proposed Revision of Tmportant Message from Medicare and Related Paperwork
Requirements (Vol. 72, No. 3). January 5.2007

Dear Ms. Lovett:
I am writing to commen1: on the Centers for Medicare & Medicaid Services' (CMS)proposed
revision ofthe "Important Message from Medicare" (1M) and irs relared paperwork requirements
as subrnirted LO rhe Office of Managernenr and Budget. This revision seeks to irnplemenr the
revised regulations on nori ficarion of Medicare beneficiaries regarding their hospital discharge
appeal righn. which were published on.Novcmkr 27,2006 in rlle Federal Regi-vfer-. While 111e
revision addresses nzany of the practical problems idenrified during h e first comment period.
there continues .LO be many issues thar were nor addressed. Ccspite rhe revisions, this
rcquirernent c~ntjnuesto n p m c n r s significant burden on hospitals. espccidly rub hospitals.
The burden is directly relarsd ro the riming of the nolice. At adinission or even shonly thereafrtr
i t is nearly impossible to accurately prcdicr a discharge date. Jn addition. ar rhc poinr during rhe
stay and prior to discharge 11mr the discharge date can be accurarely idenrified, the sraffneeded to
accurately administer and explain the Ieacr and process may noL be available. Illis person,
generally s nurse case manager or social worker, must have LIIC abiliry to explain medical
necessity and rhe discl~argcplanning process. These staPfmclnbers rcquire vast education and
hlgher salaries. In addirion. utili~ngnurses to adnlinistcr rhis proccss takes rime and resources
away from patient care a\ a rime when nwscs ore already difficult LO recruit and retain.

The proccss for administering the letrer when d.r~patienr is no1 competent is unachievable. A
significant number of elderly patieurs are admiaed wi~houra family member or other detisionmaker. These individuals do no1 have fax machines, email, and orlrtr high-rcch equipment ro
facilitate the signing and education of the form, especially if the form musr be updated
frequently. Even telephone consent is dificulr in this cases and in-person signing is impossible.

This process must be flexible enough 10 allow for rhese situa~ionsand for si~uationswhere no
decision-maker exisrs.

Tl~eprocess can be implemented effecrively, efficienrly,
accurately by focusing rhe groctss
and beneficiary quesrions on the front-end of the admission. Changing h e process in this way
will srill dlow realisric beneficiary expectations about Iml0Spi~2I1
admissio~sby improving
understanding of how decisions are made and how rhe dischargz planning process works. This
cducarion could be reinforced at discharge with discharge insrructinns.

Last, considenrion must be givcn for the majority ofparients. who despite careful and extensive
explanation become fearfd and anxious ar a time when unduc szress is detrimental ro rheir
physical healrh and healing. Patients, for the mosr part. do not understand "mcdicslly necc+ssaryl'
or admission crireria, but insread want cart provided consislcnr wid1 perceived need. In addirion,
~ e do
y not unders~andan "expected" or "estimated" date ol'discharge and feel rhey are being
forced out of the hospital. Some of these parients are so fearful slut rhey will be held financially
responsible hat they will elect 10 be discharged at the poin~01'~llcletrer. CMS must bear some
of the burden for proactive. prt-admission educarion of expectarions and coverage.

~r

Sincerely.

A.

elth e r ~ # , CPA FHFMA

1'A

.

C/4d

Lev-

FAX:

FROM:

LWN

m

F A X Ir

&I Northwest Medical C a t e r

OMB H u m R e s o l u w and Housing B r a d
Attenlion: Carolyn b v e f t

New EktcuLivaO m = Buildiog
Room 10235
\Vv&ington,

DC 20503

Reprding: CMS Proposed Rcnaion oTImpmtamf Mesage from Medicart and Rd&d
Paperwork Requirements

llunk you far the s w l t d oppomurity (o comrntnr on Qe eboveprogosad wle. Zbie ir
an i n d b l e undu(aking for horpitdrr. I rup~arithzb a i c m HoqJitd Associalion's
recommendationsm heir w p o n r t of Mar& 6,2007.
Tbc sccoodmlice k a newly prin~edd d v p w document given (o the patient rs
a p u of the patieat's d r ~ h a y einshuclion package.

LetiWe for hospiJ s fo usr. any mrans a f mmmuniwtirmnccusary for tbc notioc
prooeci wiU~IxaeGciery npraent8tiws &lb docwnenfalioo 8ccordingly.

Tlre needed clm6wtions to chc Tom) st ~egcs+adby Ibc AHA
The di~baegcrights for Medicare bmeficiaricr are a)rtrdy givrn to pelimls whcs
sdmined b BEkospihl,Tbc CMS Propod Rcvisim will jurl add (D (he wlwiuour
pqpmvork pmllrnhalready r a t h e ss twU. J ~ s m lhel
s at some point during the
hotpilalivrtion that Ihey, or respoonihlc paumr, review h e Wornration nccivrd tlp
(ime 01admissioo. Hospitals have their ~spooribililisand BO should Medicere
bu~cfidarits
or rnponsiblc pusons far chow beoeficiariej.

Kathy b s o n RN. BSN
Ulilivlion Mulagernen(

NORTHWESTHOSPITAL
& bfEDICAL CENTER
1550 North 115th Street Seallie, WA 98133
(206) 364-0500

wwwnwhospitalo g

1

May 04,2007

OM13 Human Resources and Housing Branch
Attention: Carolyn Lovett
New Executive Oflice Building Rm 10235

WaslLirxlon, DC 20503
Re: Yroposed Changes to the "Zmpoi-tant Message from Medtcnre" (IM)

I appreciate the opportunity to provide comments as to how the chnnges, if irnplemenred,
will impact our process and increase administrative time that would be bener spent caring
for your beneficiaries.

Since AuOyS(2003,[he IM has not been required 10 be rignkd by the ba~eficiaryand a
copy retamed i.11the medical record. Rather, the IM is currently given to the patient ~ O I
their information upon adrmssion. This change was driven by CMS wishes to decreae
the amount of papclwodc Medicarc patients asc inundated. As proposed, thc LM will bo
givcn twice, increasing thc paperwork givcn to your bcneficiarics, which goes against the
fimdammral basis of thc O m ' s Paperwork Rccluction Act.

If the 1M is issued and signed by the beneficiary upon adtnissiou or within 2 days of
admission, it is redlmdant and a great hardship on staff to c o o r ~ t the
c distribution of
rhe 2'ldcopy within the proposed time parameters prior to dischargc. Disblbudng
notice will require substantial coordination of both cIinica1 and clerical staff. *fie effort
j u t LO 'ensure' the patient is aware of their discharge rights when they would luve been
presenred with the information,signed that it was received 1 or 2 days prior wears
unnecessarily redundant.
Plme rcconsidcr thc proposcd changes as follows. Rcinstirutc the practice of having
beneficiaries sign and date the IM, a copy then being retained in thcir mEdical rccord
However, eliminate the proposed process of issuing a 2" norice p~iorto discharge.
Thank you for yo11 w~lsideralionand the opportunity to provide conlmenfs.
Sincerely,

S& Blair
Patient Access Managa
Northwest Hospital & Medical Center

Fracdtd & CummPnitg M t h
Comments to April 6,2001 Federal Pegistui Val. 72, No. 66

May 2,2007

OMB desk ofiiccr:
OM3 Human Resources and Housing Branch
Anenlion; Carolyn LoNew Executive Ofice Building,
Room 10235,
Washington, DC 20503
Fax Number: 202-395-6974
ComenLF for Medicare discliorge nolice changs

RE.-

Dear Ms. Lovm:
Fmedtert & Community Health, Inc, Milwaukee, Wisconsin, ("F&CWB)apprscial:es the opportuni~ro
provide comments on he Notification Procedures for Hospital Discharges- Important Message h m
Medicare notice published in the ApiI 6,2007 Federal Register! Vol. 72, No. 66 and the Detailed
Notice of Discbage. The following commcntr and questio~scegarding the propobcd pcedures
which w u c compiled by key clinical and financial representativesofFroedtert and Community
Health. Your consideration ofthcvr cammmts would be gmuly appreciated.

I;UOPOBTANT MESSAGE FROM.MEDICARE - FORM REVISIONS
F&CH supports the AHA recommendations for the following actions ta minim& the admhnastive
burden ofthis new notice and process:

-

Elimiaatt thc requirement Umt thc r t p u t notice ar discharge be a copy ofthe notice signed
at admissioa. Since beneficiaries would receive a copy ofthe signed notia when they sign
it, it would be simpler and less budensme to allow hoqitals to provide just the generic
notice language at discharge. We agree that it would be ~ i ~ c a o tmore
l y effrcieat to simply
p d the notice a s part of their discharge instruction package.

-

Afiw the first year of implementing this Dew process, perform an evaluation of whether the
Eew proccss has yiclded suficient benetit to warrant this significant inrrease in
adrninistaivt costs. Too oftcn, administdve r q u ~ e o tart
s adopted to address

anticipated or perceived problems. That has already happened once with this requirnnmt It
was adopted by statute when thc inpatient prospective payment system was ensacd and them
were widespread fears of "quicker, sickcf' discharges. fhose fears were notrealized. Thcrc
also was an earlier r c q u h n ~kt
~ ~beneticiarics
t
to sign for nceipt of the notice; that too was

found to be u n n e c e s q and subsqutdtly tlirninatch

Froedtert 4: Community Health
~ e m m e n bta April 4 t007 Fcderrl N i s t r r l V d

NO. 66

-

Provide significant latitude to hospitals in how they provide *rhe notice to beneficiary
representatives i f the beneficiary is unable to receive or undemand the notice. This issue
was raised during comment on the proposed mle, and the preamble discussion ofthc final
rule indicated tha~CMS p h e d to providc gu:danec regarding how hospitals and h d t h
plans may deliver the appropriate notice in cases where a bene!iciaq's representative may
not be immediately available. Such guidance was not included in tbe ktmdions for the
notice. We urge CMS to allow hospitals to use my means ofcommunication (telephone, fax,
mil.,
ea.)n#essary to conduct the norice process with beneftisry representatives and
allow recard notations when these alternativesa, in-pcrson notice are used.
(AHA, Lsslie Nowalk, March 6,2007)

-

N0Tll;XCATXON PROCEDURES FORJIOSPITAL DISCRARGES DETAILED NOTICE

OF DISCHARGE
F%CH continues to share concern chat if the detailed notice of discharge is issued, thac should be
minimal or no p c c days offacd. The financial responsibility of the patient should begin the day
aRer issuance, dependent on the speed of the QIO decision.

F O R M REVJSIONS:
1. There is not a signature line for autheaticrioa o f p a t i e n t ! ~ c i w e rcccipt Similar to the
statement on the IM form:

Recommend inclusion at the end of tbe debiled notice:
Signature of Patient or Rqmentadve Dme
If this is completed, could m o v e noticc date from the top -.on.
Oncc again, hoedtcrr & Community HeaIth, Inc. would like to cxrcnd its appreciation to you

for the
oppowity to comment on the above manus. If you have any questions or concerns about the
comments within, please fecl free to contact Nancy Schallert at (414) 805-2859 or via mail at
nschdl@hlh.&.

Yanc y Schalierr

Diracrcx of Compliance and Intuna1 Audit
Froedtert and Community Health
9200 West Wisconsin Avenue,
Milwaukee, WI 53226

May 6,2007
OMB desk officer
OMB Human Resources and Housing Branch
Attention: Carolyn Lovett
New Executive Office Building
Room 10235
Washington. DC 20503

Fax X202-595-6974
Re: CMS Proposed Revision of Lmportant Message from Medicare and Related
Paperwork Requirements (Vol. 72, Pi0.3). January 5, 2007
Dear Ms. Lover
I appreciate the opportunity to comment on the Centers for Medicare and Medicaid
Services' (CMS)proposed revision of the "Important Message fiom Medicare" (M) and
its related paperwork requirements as submitted to the Office of Management and
Budget l h s revision seeks to implement the revised regula6ans on notdication of
Medicare beneficiaries regarding their hospital discharge appeal rights, published on
November 27, 2006 in the Federal Reglsrer.

Currently we do give patients the IM upon admission. This is done by our Registration
d e p m e n t and is included wirh the admission paperwork. In the new law, we will be
required to give the patient the IM w~rhintwo days following admission and hospital
staff must ensure that the beneficiary understands the notice and s i p s a copy of it
documenting when they received and that they understand i t A copy of the signed notice
xvill be given KO them at that time. We will then provide another copy of the signed
notice no more than w o days prior to discharge.
While I understand and appreciate the idea of informing patients about their rights, these
new repladons will create a significant additional burden to our hospital.
It will be difficult to reach all Medicare patients with the new LV unless we change
several key processes and hire additional staff just to comply with the new law. This
comes at a time when we are short of clinical staffand because of economic Qficulties
in this community are limited in hiring replacements.
It has been suggested that in order to not miss any pauenrs tvho may be changed fiom
post procedure recovery or observation sutus to inpatient status that we give all Medicare
patients coming to the hospital a copy of the IM, rhis means a ,oreat many patients given

the IM will not need it and may be confused when they are not inpatients about their
discharge appeal rights.
Lfwe target only inpatients then it would take a full time stafTmember to @a& these
patients. One plan being discussed is to wait until the physician says the patient will be
discharged within the next two days. Since most physicians do not know that far ahead
that the patient will be discharged, we will most often be giving the patient a letter on the
day of discharge. We also need to take into account that the patient will need a period of
several hours to consider their right to appeal the discharge. This may postpone a
patient's discharge time.
In a recent patient satisfaction survey, one of the most common complaints regarding the
discharge experience were delays in discharge m e s . We are currently working on
processes to improve that problem but the new law may acmally bring about farther
delays and negate any gains we have made in this area.
In order to comply with the second notification requirement we could give every patient
staying more than 2 days a letter every third day. That would ensure compliance with the
law and would perhaps avoid some delays in discharge times. However. it would require
one fill time staff member to see all these patients.
lie solution to this issue is not easy and I do understand the importance of m a h g sure
patients understand their rights.

Several questions come to mind. Could there be more fleqbility in issuing the IM's?
Would we be able ro give the patiem this information upon admission and rhen,qive &em
a copy at the time of discharge? Can there be a pilot study done at selected faclllties
(especially in urban areas) to find an efftcient method of giving the patients informaption
and not burden the hospitals unnecessarily? Could there be a community program for
educating everyone who has Medicare about their rights before they become ill and are
admitted to a hospital?
Sincerely,
John Clark RN,BSN

Manager, Integrated Case
Managernen1 Department
Good Samaritan HospiTal
2222 Philadelphia Drive
Dayton, Ohio 45406

4%

5 Greater New York Hos~italAssociation

May

Four
2007

Ms.Carolyn Lovett
OMB Desk OEcer

O M .Hunan Resources aud Housing Branch
New Executive Offiw Bui lling, Room 10235

Washingron, DC 20503

RE: CMS-R- 193 (Om#:0938-0692) Proposed Revision to Important Message fiom
Mcdicarc and Related Papcrrwork Requirements (Vol. 72, No. 66), ~pril6,2007
Dear Ms.Lovett:

Greater New York Hospi:~lAssociation (GNYHA) represents more than 175 not-forprofit and public hospital:: in New York State, New Jersey, Connecticut and Rhode
Island. We welcome the opportunity to comment on the Centers for Medicare and
Medicaid Services (CMSj proposed revisions to the hportanr Message fiorn Mcdicare
(IM). The n w l y revised :Id associated with CMS-4105-Fwould set forth requirements
for how hospital9 musz nla~tifyMedicare beneficiaries who are hospital inpatients about
their discharge appeal rigf Is.
We appreciate CMS's an.:.mpt to creak an enhanced process for informing Medicare
bencficiarics of their discl~argeappeal rights and for inoorporating meaninel changes
into the proposed process in respame to GNYHA's and other previously submirted
comments. However, we c:;nlinue to have a number of lingering concerns with respect to:
The cxccssive fim.ricia1 burden that hospitals will encounter as a result of these
ohanges; and
The fact that hosp~talswill not have adequate preparation time to implement
majot changes in ;~~lmission
and discharge procedures and to develop new forms
to accornmodale Lbl:' new Medicare requirement.

Accuracy of the Estirnatc:rl Administrative Burden

We believe that CMS has significantly underestimated the cost burden that hospitals will
incur as thc; endeavor ta implement procedural and other changes in order 10 comply
with the requirements of .:le new process for notifying Medicare bencficiaries of their
hospital discharge appeal rights. The CMS cstimsres do not accurately consider the

specific manpowex demand; or the additional supply expenses thathospitals will assume.
Previously, hospital admisarionclrrLs issued the JM at the h e of admission; rhe newly
revised CMS process will likely require that hospitals designate more highly paid staff to
deliver the IM who are c:lnversant in the areas of regulatory, medical necessity, and
discharge plsnaing becauit: of the emphasis on the discharge planning process in the
revised IM.In addition, t h s CMS estimate only talces into account the expense associated
with delivering the follov~up IM to 60% of hospital Medicare admissions because it
discounts short stay admit:;ions. In fm,CMS should consider the expense associated
with issuing the signed col-y of the I
M ro 100% of the Medicare beneficiaries shoe ow
membership indicates to u.1 that, as a practical matter, a uniform process must be enacted
to ensure all Medicare pa:ients arc captured, not just 60% of the admissions or those
admissions with h g t h s of'8:tay of greatm than 3 days.

CMS should demonstrats i:reatcr flexibility and endorse a more reasonable process for
issuing thc admission an,:[follow up IM when the Medicare patient has dimmished
capacity to comprehend thr: IM. Hospitals will inour significant administrative burdenswhich have not been comi3ered in the CMS cost estimates-in order to locate a distant
family member or other rejiresentative authorized unda the CMS standards to receive the
notices. This patient pop~lil~ion
is not insignificant and notably includes patients admined
directly to critical care arcas, nursing home residents, and psychiatric patients. With
particular regard to this su'klset of patients, we strongIy urge CMS to be cogni7ant of the
administrative burden on ,:r roviders by relaxing the proposed timefiamcs for issuing the
admission IM. Lnsread of requiring the admission IM to be issued within 2 &ys of
admission, the timeframe :,l~ouldbe waived if a hospital can document reasonable ef5orts
to locatelcontact the nexl of kin. In addition, CMS should endorse more practical
signature requirments a1.d accept fax or email con5rmation or other telephone
documentation of good fai111and repeated attempts as acceptable proof of compliance.

GNYHA urges CMS to sh~:wgreater flexibility and permit hospitals to issue and explain
the rM during the preadmi3;ion testing visit when an elective inpatient service is planned.
Bccausc a significant numlxr of Medicare admissions are clective in nature, it is f a i b l e
that this subset of Medicare patients could receive the initial IM at the time of
preadmission testing, gener-lllyup to a week in advance of admission, rather than waiting
until the adrnissic~ndate. :?atitmuare generally more at ease at preadmission testing, are
often accompanied by a fal-lily member, and therefore better able to assimilate important
information about the hcspital discharge notice. This approach would be clearly
advantageous for the Merficare beneficiary and at the same time assist providers to
achieve compliance with !he process for issuing the admission IM for a substantial
portion of Mcdicarc hl: spital admissions. Should CMS adopt this particular
recommendation it could come with the understanding that hospitals would not be
exempted from issuing the Iollow up IM for short stay elective admissions of three days
or less.

Implementation Issues a114Clarit). of Notice

When CMS implcrncntcd :lie Fast Track Appeal process pursuant to BIPA for post acute
care providers, it ~ o l v ~ the
~ : Nwr
l
York QIO to conduct educational sessions for
affected provider3 regardirt:.: the new procedures. To date, we have not ~ c d v e dany h
confirmation chat CMS wi' I similsrly provide this needed education for hospital providers
in advancc of the July 1, :!007, effective date. Because the implementation timeline is
rapidly approaching and tl-c different notices ate either still not finalized (i-e., XM and
dmailcd notice) M o r nr. yet released (i-e., liability noticc), we are wncemed that
providers do no1 have aill:quate time to internally prepare and make the significant
changes to existing procediires.

Finally, as a matter of ~'~rmat,
we ask that CMS consider moving the additional
information section currcr~tlylocated on the second page of the IM to the first page to
simplify the recording of 3gnatures in order to lower administrative cosls and facilitate
compliance. We are I t m i rlg that many lrospitals will incur additional expense and will
be developing a triplicate I;)rm using cabonless or NCR paper to facilitate capturing the
patient signarures at admiii;ior\ and prior to discharge on the IM and then retaining the
final copy as proof of wrnpliance.
We appreciate your consideration of these commeats. If you have any questions or would
Iike further information, please contact Lillian F o r g a , Associate Vice President
Utilization Management a:.dManaged Carc, at (212) 506-5534 or for~acs&n~ha.org.

MYbest.

@seton Family of Hospitals

A

May 4, 2007

OM6

Human Resources and Housing Branch
Attention; Carolyn LoVett
New Executive Ofice Building
Room 10235
Washington, DC 20503

VIA FAX 202-395-6974

Re: Centers for Medicare & Medicaid Services
[Document Identiher: CMS-10003, CMS-901A and 0,CMS-9044, CMS-R-193 and
CMS-100661
Agency Information Collection Activities: Submission for OM0 Review; Comment
Request
Federal Register / Vol. 72, No. 66 / Friday, April 6, 2007 / Notices Page 17169

Dear Ms. Lovett:

The Seton Family of Hospitals appreciates this opportunity to comment on the
Centers for Medicare & Medicaid Services' (CMS) proposed revision of the "Important
Message from Medicare" (IM) and its related paperwork requirements as submitted
t o the Office of Management and Budget.
By way of background, the Seton Family of Hospitals consists of several facilities i n
Austin and central Texas: four general acute hospitals including the regional trauma

center; a children's hospital; an inpatient psychiatric hospital; three community
primary care clinics and specialty care clinics that serve the working poor; and two
critical access hospitals in outlying counties. Seton has determined that the CMS
proposed regulation places a significant increased financial and work burden on our
hospitals. Consequently, we respectfully request that O M 0 require CMS t o modify
their proposed regulation to reduce the burden.
Hospitals currently ~ r o v i d ethe IM to beneficiaries when they are admitted to the
hospital, generally in the patient's admission package. The I M explains a
beneficiary's right t o have their discharge decision reviewed by the local Quality
Improvement Organization (QIO) if they believe they are being discharged too soon.
The notice provides all the information needed by a beneficiary t o request such an
appeal and explains that they will not be held financially liable for corltinued hospital
care while the QIO reviews their case. A more detailed notice with specific reasons
why hospital care is no longer required is provlded when beneficiaries indicate that
they are not comfortable with the planned discharge date.

Under the new regulations, which take effect on July 1, the I M will be provided to
beneficiaries no later than two days following admission. However, hospital staff will

be required to ensure that the beneficiary understands the notice, and signs a'copy
1201 West 3 8 t h Street

A u S t ~ n .TX 7 8 7 0 5

( 5 1 2 ) 324-1000

WWW.SetOn.nO?

Our mission tnspires us to care for and improve the health of those we serve with a special concern for the wck and the poor.
We are called 3 Senice of the Poor. Reverence. Integriry, widom Creativi~and Oedic~ion.

of it documenting receipt and their understanding of it. A copy of the signed notice
will be given to the patient. The hospital must then provide another copy of the
signed notice no more than two days prior to discharge. Detailed information about
a particular discharge will be required only when a beneficiary requests a Q10
review.
While we agree that bcusing the process and beneficiary questions on the front-end
of the admission will help form more realistic beneficiary expectations about hospital
admissions and improve a patient's understanding OF how decisions are made and
how the discharge planning process works, the process that CMS will require starting
3uly I comes a t a heavy price.
Even with CMS's relatively consewative burden estimate included in the paperwork
clearance package, CMS projects that the burden on all hospitals will increase more
than fourteen fold. Using the CMS formula, Seton estimates the burden on our staff
and facilities will increase from 1,252 to 17,969 hours.
Further, the former notice was provided by admissions clerks. The new process will
require someone with the ability to explain medical necessity and the discharge
planning process generally a nurse case manager or social worker - to present the
paperwork. Seton's average hourly wage for clerks is about 814.50, while the
average hourly wage for nurses and social workers is about $26.00. Conservatively,
this single change in regulations alone fakes our cost from $18,200 t o $434,600 per

-

year.
Seten Family of Hospitals urges OMB to require CMS to take the following
actions to minlmlrze the administrative burden of this new notice and
precess:
Eliminate the requirement that the repeat notice at discharge be a copy of
the notice signed a t admission, Since beneficiaries would receive a copy of the
signed notice when they sign it, it would be simpler and less burdensome to allow
hospitals to provide just the generic notice language a t discharge. We believe that it
would be significantly more efficient to simply print the notice as part o f their
discharge instruction package.

After the t k t year of implementing this new process, perform an
evaluatlon of whether the new process has yielded suHicient benefit to
warrant thls significant increase in administrative costs. Too often,
administrative requirements are adopted to address anticipated or perceived
problems. History is repeating itself in this instance. A similar requirement was
adopted by statute when the inpatient prospective payment system was enacted and
there were widespread fears of 'quicker, sicker" discharges. That did not happen.
There also was an earlier requirement that beneficiaries sign for receipt of the
notice; that, too, was found to be wnnecessary. Both of these earlier requirements
were subsequently eliminated.

Provide significant latitude to hospitals in how they provide the notice to
beneficiary representatjves if the beneficiary is unable to receive or
undernand the notice. This issue was raised during comment on the proposed

rule. and the preamble dlxusslon of the final rule indicaxed that CMS planned to
provide guidance regarding how hospitals and health plans may deliver the
appropriate notice In cases where a beneficiary's representative may not be
immediately available. Such guidance was not included in the instructions for the
notice. OMB should direct CMS to allow hospitals to use any means of
communication (telephone, fax, email, etc.) necessary to conduct the notice process
with beneficiary representatives and allow record natations when these alternatives
to in-person notice are used.

CMS should post an its web site the text of the notlce translated into the
t o p 15 languages hospitals frequently encounter. Almost one-fifth of the U . S .
population speaks a language other than English at home. Hospitals are required to
provide language services for such individuals, but they do not receive compensation
for the cost of those services. The size of this population and the vast number of
languages now being encountered make it very difficult for individual hospitals t o
provide translated documents. Since the text o f this notice cannot be altered by the
hospital, CMS should obtain and provide translations of the key beneficiary notices.
The Soclal Security Administration has a list of 15 languages that it uses for such
purposes. The American Hospital Association's research affiliate, the Health
Research and Educational Trust, recently conducted a survey of hospital language
services which found 15 languages that a t least 20 percent of hospitals encounter
frequently. They are: Spanish; Chinese; Vietnamese; Japanese; Korean; Russian;
German; French; Arabic; Italian; Laotian; Hindi; Polish; Tagalog; and Thai.
If you have questions about our comments, please contact me or Ed Berger, Vice
President, Advocacy & Government Relations, at S 12-324- 1948 or
eberqer63spton.org.
Sf ncerely,

\fJxd%h3j
Jesus Garza
Executlve Vice President & COO
Seton Family o f Hospitals

OMR Cesk 3ffi-r
OMB H u m Resot~rcesand Housing Branch,
ACention: Car~lynLovett
New Executive Office Building,room 10235
Washington, DC 20503

April 18,2007

w

To Whom It May Concern:

I am writing with comment; related to h e Zew "Important Message from Medicare" and
the "Detailed Notice of Discharge " I work for a Catbclic Health system, Carondelet
Health, that Is part of the much iarger system, itscension Health. I am iae Director c,f
Case Management for 2 acute care facilities. I have several concerns related to this new
proposed regulation, and truly appreciate the additional opportunity to comment.
1. I undmst.sxx?the :ntent of presentkg the TM gpon gdmission, but do not feel that a
s x o r , i c?py i: necessary. For example, do we ha& ken sign a C o x e ~tct Trea:
fu.51st idinissi,on a3d ???ina& discharge? .
.
2. Tc Fr~:-.'it th'r "7. dnys pior t~ di~hw,;~",will he impossible to administer and.
1co12inin :aaplizzre frcm CMS's point of view. ljip~p'talstays 2ue much shorter
now,things pmgiess quickly fmm the momkg to the .afternoon. A paiier~that
W E S stilt 1rnCcrgcing testing and w c r h p in the morning, may be stable and ready
for dir,&wrg?by ear!? evening. We are behg set up for failure to meet the
guidelines of fie 2 days prior to discharge r,otif.i,cation. What will be the
ramifications if a hospital is not meeting this regulation?
3. In the medical field where there is already a nursing shortage, we are asking
nurses to spend valuable time that will take them away from the actual bedside
care, to make copies and present the document to patients a second time. This
. seems very unnecessary. Our hospital has determined that nursing would be the
staff to present the 2ndcopy, as discharges occur at any time day or night and they
are the front line staff that is first aware of the planned discharges.
4. A concern is that presenting this twice to the patiqnt'will canfuse the elderly
- .
population and do more harm that good.
'I
5. The wording of thc regulatim~~states
"Hospit$s \will ddlver a copy of the signed
t
than 2 drys v~,frjle
dischpge." h i s is very
notice prim to disckarge, but n ~ more,
c o w g . .Ghn'&e, deliye: js 3~ tb5 dpy pf discharge? -0';at thetime of
dkcharge? Our hterpatatior! is that it c6uid be delibered at the time of discharge.
IS chis,c01~e&? .
. .
j . l ; .
6. This .tr,tirc precess seems very contradictory to'ihe 'Qap&ork ~educfionAct i f
I

1995".

7. We work under the assumption to treat all patients the same regardless of

insurance or ability to pay. By oniy providing this paperwork to Medicare
recipients, we are singling out a certain payor source with required documents.
Presently our nurses are not aware of the patient's insurance.
Sincerely,

Cynthia L.Burress RN BSN CCM
Regional Director of Case Management

MAY-09-2007
4058493573

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15:51

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202 395 5167
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INTEGRIS
3

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May 3,2007

OMB Human Resources and Housing Branch
Attention: Carolyn h v e t t
New Executive Office Building
Room 10235
Washington, DC 20503

Dear Ms. Loven:
As previously requested, we would like to rake this opportunity to express our concern
with the proposed CMS-4105-Frule regarding Notification of Hospital Discharge Appeal
Rights. %le we do not have an issue with providing a revised IM to the patient at the
time of admission and discharge, we feel that the proposed pmhibition to provide this
document on the day of discharge provides an added adminiskalive burden to our facility.
We do concur that patients should have the right to appeal their discharge but also believe
rhat the patient or histher representative should bear the responsibility without placing

added burden on the facility.

While the proposed rule states that the patienthenefxciary is not required to verify that the
notice was given it does require the facility to be able to document that rbe nonce has
been delivered. Again we feel that this requirement provides added adrninisuative burden
on our facility.

We would request that you review these comments and reconsider implementing this rule
prior to July 1,2007. Thank you for your cansideration.

Chris M.
President
INTEGRIS Baptist Medical Center

P .30/30

CMS
Page Two

hospital given the prior track record as mentioned earlier and do not bdimc that the
American public is not aware of its rights or entitlements, a s you are well aware. I
believe this will actually deteriorate the ability to provide care and savices to rhc patient
as scarce rcsourccs will havc to be once again diverted from patient care to regulatory
rnarrdates. X truly believe the position of CMS is to ensure that patients gat good. timely
carc and that this is providcd in a financialIy rcsponsiblc mechanism,but 1 think you have
to be aware ofthe unintentional consequences that. given scarce resources, most likely
the patiarts on the whole will suffkr by the lack of case management having resources
diverted to fulfill this mandate. 1would very much be willing to engage in ftrther
convcrsa~ionregarding this well intentioned, however misguided, mission,.
Sincerely,

David S c h w a , DO

>

MAY-09-2087

15: 50

OMEI,~OIRA

202 395 5167

Nm
W Northwest Medical Center
62CO N.Ld ChOlla Dnulcumd
Ttum. Arizona 8574 1

P h :520-742-9000
w.northwe~aedicakm~r.m

April 30,2007

The Centers for Medioare & Medicaid Services
OMB Human Resources and Housing Branch
Attention: Carolyn Lovett
New Executive Office Building
Room 10235
Washington,DC 20503

Fax: 202/395-6974

Re: Medicare Discharge Notices
To W ~ o mIt May Concm:

I am the Medical Director for Northwest Medical Center and also provide oversight for
thc Hospitalist Program at Northwest Medical Center and Oro Valley Medical Center in
Tucson, Arizona.
I am in receipt of your plan to provide Medicare recipients a second letter one to two
days prior to discharge further reminding them of their rights as to appeal. As you wcll
how,zt the time of admission, Medicare patients are given Medioarc rights, including
their rights to appeal their discharge. To give a second lcrter one to two days prim 10
discharge, again re-stating their rights creates a number of problems.
By doing Lhis, you are assuming that patients do no1 understand thcir rights; or are
incapable of understanding their rights at the time of admission when they sign. I can tell
you in the appeal process of patjents that have been discharged in the last 12 years, other
than onc appeal, every one of the dedals for continud stays has been upheld by you. I
do not see any abusc in this system by the hospital. I believe tbis is an incredible waste
of resources which would bettcr serve your patients, instead of handing out pieces of
paper reminding them of their rights which they have already b w infarmcd of, that this
could be time better spent in managing the patients' care such as dischnge planning or in
attending to other needs of the patients and heir family. This also further crcates issues
with regards to thc appeal process. I can assure you when patients don't want to leave the
hospital they are well aware of their appeal time and often will utilize up to the maximum
ultil the time that their appeal has been denied. Unforlunately, we we in a society in
which pcople will take advantage of the additional 2 ~ 4to 48 hours in the hospital and this
furt~erreinforces this. I don't believe that p q l c have been unfairly discharged from the

P. 28/30

MQY-09-2007

15: 50

r3PIBiO I F.n

_.--... -...-..

202 395 5167
I
.
.
.
"

P. 27/30
qg U U L

. ...
I

Pf?wheaton Franciscan ~eaIt)lcare
S p c m w by the Wcrlo?F r u u ~ ~ c s5-n

May 2,2007

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

RE: Form Number: CMS-R-193 ( O W # : 0938-0692)
Dear Ms. Lovett:
Wheaton Franciscan Healthcare is a health care delivery system with hospitals in the states of
Wisconsin, Illinois and Iowa. Wheaton Franciscan Healthcare appreciates the opportunity to
comment on the revised Important Message from Medicare form.
In order to streamline the process and assure that patients receive the second notice, we are
planning on printing the Important Message from Medicare on a three-ply carbon form. The top
copy would go to the patient, the second copy would be delivered to the patient within two days
of discharge and the third copy would be placed in the medical record. The three-ply form will
cost 40 cents as opposed to plain paper which would cost 4 cents. The 4 cents does not
include labor costs for locating the form and then making copies of the form for delivery to the
patient.
Given that this from must be scanned into our electronic health recard, the form will require a
bar code and will have certain margin requirements, as all our forms now da. After a logo is
placed on the form, we will still need a larger margin that is on the proposed forrn, All forms now
require a 314" in margin. We also place stickers on forms that include the patients name and
certain dernagraphic information. This sticker needs to be within the 314" margin. We ask that
hospitals be required to utilize the content of the forrn but be allowed to modify some of the
formatting, including spacing, as well as where the demographic information and date are
placed, so that the form can be compatible with various electronic health record systems.
The 'Additional Information" space for additional signature and date lines will be helpful for our
documentation purposes. However, given our electronic health record requirements, space for
such items is very limited.
Please let me know if you h a v e any questions about our Comments. I can be reached at
630-909-6903.

Compliance and HlPAA Services

INTEGRIS

May 3,2007
OMB Human Resources and Housing Branch
Attention'.Carolyn Love#
New Executive Office Building
Room 10235
Washington, DC 2Pc'

1

Dear Ms. Love1
As previously req
with the proposed
Rghts. While we a

I

time of admission ar
document on the day
facility. We do concur
also believe that the pa
without placing added b,
While the proposed rule st
the notice was given. it dot
has been delivered. Again, i
burden on our facility.
'

-

express our concern
\ital Discharge Appeal

to the patient at the

3n to provide this
5urden to our
ir discharge but
?sponsibility
not required to verify that
,,- abl6 to document that the noti=

.~quirementprovides added administrative

We would request that you review these comments and re-consider implementing this
rule prior to July 1, 2007.
Thank you for your consideration,

-L

Sincerely,
Patricia J.
President

Dorris

Robert S. Hodges, MSN. RN
Manager, Clinical Resource Management
Midas Certified System Manager
Covenan1 Heallhcare
1447 Nonh Harrison
Saginaw, MI 48602
Email- rhodgesechs-r'ni.com
Office- 989-583-6446

Fax- 989-583-1097
Pager- 989-258-7242

A ~rornise.ofCaring, A Commitment to Service
We are what we repeatedly do, excellence is not an act, but a habit." Aristotle

H you are not the intended
recipient. or the employee or agent responsible for delivery of this message to the intended recipient, you
are hereby notified that any dissemination, distribution or copying of this message is strictly prohibited. If
you have received this message in error, please immediately notify the sender and destroy this message.
Your cooperation is appreciated.
This message may contain legally privileged and/or conlidential information

Clinical Resource Management Department

Memo
TO:

OMB Human Resources and Housing Branch
Attention Carolyn Lmtt

New Ewecutive OfficeBullding. Room 10235
Washington DC 20503

Fax 202-3954974
From: Roben S. Hodges, MSN, RN

Manager, Clrnical Resource Management Department
1447 N. Hanison
Saginaw MI 46602
CC:
Date:

511~97

ue:

Important Message from Medicare and Detailed Notice of Discharge Comments

Thank you for the opprtunrty to comment on these documents

Regarding the Important Ndce from Med~cam,CMS-R-193, at this t~meI feel a block needs to be
added to allw pat~enWarnilymembers to lnn~aland date that they have remved t h r second notice

Regarding the Ceta~ledNotice of Discharge, CMSR-10066, I feel this document is to Mgue to k
useful to the hospital when attempting to prepare a n o t e . A format closer to the Hospital Issued
Notice of Noncovwage for continued hospitalization may hf! more appropriate, I feel the instructions
provided are vague and for an issue like this there & need to be specific guidelines,
Other questions 1 have on this nctice are.
1

"Explanation of Medicare coverage policies that we used to determine that Med~care
wll no Imgei axw your hospital stay."

-

a.

Would VIIS include the use of a discharge screen using the utilizat~on
management criteria, in our case InterQual?

b.

H w much detail is expected? Would a statement that the attending physician
feels that you are able to safely move to the ned level of care and that you
meet the hospitals cntena to mPJe to that ned level of care be sufficient3

2 . "Medicaremanaged care plicles."

a. I presume this means the private payer policies if a patient has one of the
commercial plicies awlable.

b. Will those payers be required to prmde the hospital with this i n h a t i n if
they make the determination that the patient can move to the n& IW of
care?
c.

Will a hosprtal have to use the guidelines provided by the payer or use ther
own guidelines to determ~neappropriateness for tmsferMrscharge to the ned
level of care'>

d.

Also based on ths notice and the content it requires. I feel that the staff
milable to prepare and delver this notice must be at least at the level of an
RN or an RN must be amilable to assist in prepamtion af this document along
with the attend~ngphysrcian. Has consideration been glven to this. spectally
for weekend. and nollday zippeak? I antrcipate a possible requirement for
additional FTE's to support this program or at a m~nirnurna reallocation aR
exsting staff to support the veekndlhdiday discharge requirement.

Omall. I feel thrs will cause an Increase In length of stay n the ~npat~ent
hosp~blsetting because of the
time frames ~nvolvedshould a patient appeal the~rdrscharge and that more patients will appeal their
discharge slrnply because they don't feel "ready" to go to the next level d care, or in same cases they
do not wsh to go to the ned 1of care.
Thank you for your time and considerahon. I will look f w r d to the final notice and further changes to
the implementation of this policy.

Sincerely,

Robert S.Hodges. MSh, RN

a Page 2

riw-89-2007

is: 47

OMB/O IRQ

qpaageg

Leesbw~Regional Mcdicul Center

Regional Hospital

May 3,2007

OMB Hunan Resources and Housing Branch
Attention: Carolyn b v e t t
New Executive Office Building Room 10235

W&ington, DC 20503

RE:(CIMS-1003, CMS-901A tuld D,CMS-9044,CMS-R-193and CMS-10066) hnporlant
Message kom Medicarc (72 Fcderd Register 17169), April 6,2007

Dcar Ms.Lovett:
We appreciate this opportunity to comment on the Centers for Medicare & Medicaid Services'
(CMS)proposcd revisions to the Important Message from Medicm (IM),as published in the
April 6,2007 Fcdcral Register.

The first area of concan is with regard to the delivery a1v-I signing of the IM. h order for us to
colnply with providing s bcncficiary with a copy of tbe IM wilhin 2 calendar days of admission
and the11 follow-up with a copy within 2 calendar days of discharge, w e would nccd to involve
wily depsrhnents ill the process (Admitting, Nursing, an3 Case Management). It was estimated
that the averase time fir I
M delivery was 12 minufes and the delivery of the copy was 3 minures.
In cmain instances where the beneficiary is eat in the room because they are having additional
tests run or if the beneficiay is a b l e to comprehend ~ h information
c
(due to competency or
language barrier) this timc frame could easily increase to over 30 minutcs.
We believe that this could become quite a labor intensive and tiins consuming process not to
nluntioil an increased possibility of copy delivery failure. Tn i~~sunces
like these, we are
especidly concerned with fhe penaltics imposed for not providug a copy of the IM a second
h c ?

Also,how should instances where a baltficiary refbses to sign the IM be harldled?
Lastly, will multiple translations of the TM be made availablc (i.c. Spanish etc)?

-*
Respectfully,

Nikisha Bailey

Corporate ~ o k ~ l i a n Manager
ce

6

- MAY-09-2007

15:4rJ

OMB/O IRA

this date. It is important that hospitals be afforded at least 60 days from the time the form is
finalized and a Medicare transmittal is issued to be in compliance wiih the regulalions.
Cost of Delivery
CMS has failed to account for the full cost of the preparation of the "Detailed Nolice." which
CMS estimates will take approximately one hour. MCHC hospitals estimate that the detailed
notice will take twice as long as proposed to complete and to deliver to the Medicare
beneficiary because of the level of detailed information requested, the need to involve the
physician or a hospitalist, and the need to translate clinical information into plain English.
The process will take even longer for non-English speaking patients.
Additional Information

Thank you again for this opportunity to review CMS' proposed "Detailed Notice of
Discharge" and to offer comments. We would appreciate another opportunity to comment
on the notice once CMS has provided examples of completed forms and has provided
additional information on the guidelines and Medicare coverage policies hospitals should be
referemirlg.
If you have any questions about the issues raised above or you need any additional
information, please feel free to contact me at 3121906-6007, email [email protected].
-

Sincerely.

Susan W. Melczer

Director, Patient Financial Services

--

NFl'i-09-2007
.."A

15:46

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202 395 5167

P. 14,<.30

We are concerned that the "Detailed Notice" has been developed based on similar forms
used in non-hospital settings thal do not easily transfer to an acute care setting and that it
does not take into account how inpatient d~schargedecisions are made. We find the
language of the proposed "Detailed Notice" more applicable to services in a non-acute
setting or for a specific ambulatory servlce. For example, reference to describing "the
cunent functioning and progress of this patient with respect to the services being provided
is applicable to home health services, not inpatient care. CMS itself indicates that when it
developed the form, it "took inlo account beneficiary comments made when the detailed
notices used in the non-hospital settings for both Medicare Advantage and original Medicare
were consumer-tested." CMS makes no reference to testing the proposed 'Detarled Notice"
in an ~npatientsetting, which is where the form is expected to be used and which differs
signifi'cantly from non-acute services.
Proper Completion of Form
It is important to note that in an inpatient hospital setting, a discharge decision is made by
the attendlng physician based on the physician's professional judgment. The discharge
decision is not made by the hospital, and it is not made based on a speciric Medicare
coverage rule or policy. It is unclear to us which specific guidelines CMS expects hospitals
to use in completing the proposed 'Detailed Notice." In 2005, the Quality Improvement
Organization (QIO) for Illinois adopted the Milliman Care Guidelines for non-physician
review nurses when screening Medicare cases for referral for physician review. Should
hospital case management staff be referring to these guidelines, or to some other national
criteria such as those developed by Intequal, when it explains to a Medicare beneficiary
why an inpatient stay is no longer necessary?
The guidelines on which acute continued stay is evaluated are clinical and technical in
nature. As a result, it is not clear how CMS expects the hospital to complete the proposed
'Detailed Notice' since both detailed and specific reasons in plain English are required. Will
it be sufficient for the hospital to attach, for example. a copy of the Milliman guidelines
relevant to the patient's medical condition and to indicate that these attached criteria are not
met?

Exarn~lesNeeded
It is difficult to evaluate the proposed "Detailed Notice" without some concrete examples.
Can CMS develop a set of specific examples of completed forms for several different clinical
situations so that hospitals will have a better idea exactly how CMS expects the forms to be
filled out? It would be helpful if this could be done in such a way as to allow for additional
public comment before the form is finalized.
Implementation Date
The regulations associated with the "Detailed Notice" require that hospitals begin using this
new form and new discharge notification procedures July I. 2007. We are concerned that
the "Detailed Notice" and the administrative instructions for its completian will not be
fnalized with sufficient time for hospitals to modify their internal procedures and train staff by

May 3,2007

O m Human Resoutces and busing Bmch
CrrloIya Eovett

New Executive Office Building, Rm. 10235
Wuhiqkton, DC 20503

Dear Ms.Luvett:
As previously q m r e d , we would like to take this oppomrniry rc express ow concem
wih the pproposed ~ ~ ~ - 4 1 0 5 - P regarding
mle
No~ificadonof Hospiral Discharge &d
Rights. While we do mt have an issue wi& providing a revised M to the patient at t
b
h e of admission a;Kt discharge, wc feel that the proposed prohiition to pmvitie
document on the day of discharge providts an added administntive burden to our hciIity.
We du concuithae patients Shm!d have the righ to appeal their discharge bur atso believe
that rhe padem o: hisher repsesemative should bear the ~espansibilitywithout placing
added burden on the ficiliry .
"Nhilethe props& ride states &tr the gatienr/beoef~iaryis not required to verify &at the
nolice was givw, ir does require the kiliry to be able t docthat the notice hss
been &livered. Again we feel that h i s requirement provides addd administrative buden
on our facility.
We would request that you review these commenrs and xoccrnsMer in?plem&g
pric~
to July 1,2007. Thanfr you for your consicleaation.

Sincerely,

-Presidem
i

this de

OMB Human Resources and Housing Branch
Attention: Carolyn Lovett
New Executive Hospital Building
Room 10235
Washington, DC 20503
Fax# 202-3 95-6974

Re: Revision of Cuncntly approved collection; M :dicare and Medicare Advantage
Programs; Notification Procedures for Hospital D i s c h a r p e s - o m Message from
Medicarc
University Hospitals Case Medical Center (University Hospitals of Cleveland) has about
1,000 Medicarc discharses a montb.
We are a tertiary facility (including 4 adult ICU's! with many emerzency transfers from
community hospitals.
These patieats are acutely or critically ill witbin tie fim 2 days of their admission. This is
the time period whcre they would not easily unde:srand an IMM. Providing this with an
explanation of the d.lscharge process would rcqui~e a case manager or social worker, it
would also require a change in stafling resulting i.n an incmse in slaffand cost to be
able KO provide rhis service on the weekend.

If the patient can not understand, we would then ratted to contact a family member, friend
or guardian who would accept ads on the patient' ;behalf. Tl5s is often difficult to
detern~inethe appropriate person and to reach ths t person, and to explain it to them.
From OUT current experience in providing these Ic.rters,they often result in a lot of
or both. Thii: would be a very time consuming and
questions from the patient or
costly process. Also due to h e acwe nature of th~:illness within the first 2 days of
admission, the discharge plm may not be knom causing unnecessary conccrn for the
pati endfamily.

-

%

w

o

n

of the burden r :isplaccs on the hospital.

Kimberly C'mell
Manager, Utilization Management
University Hospitals Case Medical. Center

INTEGRIS
x~lL
May 3,2007
OMB Human Resources and Housing Branch
Aftenlion: Carolyn Lovelt
New Executive Office Building
Room 10235
Washing!on, DC 20503

Dear Ms, Lovett:

Aa C1lid Ortr~aIirly Olliuol ul INTEQRIS Hualll~,Ilre laryesl 11u1-fur-prufllI~rlrllll
cart:
system in the Stare a! Oklahoma, I am writing to express concern whh the proposed
CMC4105-r rule regarding Nelificalianel I Ioapi!al Dlseharge Appeal r[lghls. Wa d6 not
havc an Imuc wllh providing a rcvhcd IM to ttrc poliont at the time of admission and
dlscharge. However, we believe that the proposed prohibition to providing this
document on the day of dlscharge pmvides an added administrative burden lo our
hospltals that Is unnecessary. We concur that patients should have the right to appeal
thelr discharge, but we also believe that the patient or hisher representative should bear
thls responsiblllly. The placement of thIs added responsibility on hospitals, particularly
on small rural hospltals. creates an undue burden on staffs that already fill multiple roles
and deal wlth volumes of paper requirements.

rule slates that the patienVbeneliciary is not required lo verify that
Whlle the
the notice was given. It does require the facility to be able to document that the notice
has been delivered. Again. I urge you to reconsider this requirement which creates
added administralivs burden on our hospltal staffs.
I strongly urge you to review these cornrnenls and to reconsider Ihe implementation of
Thank you for your conoldenlion. Iwill be happy 10
discuss thls matter funher by telephone and can be reached at 405-949-31TI.

thls rille prlor lo July 1.2007.

"
@
"
C. B ce L r nce
Executive Vice Presldent &
Chief Operating Officer

m

HighPoht Reglonal
Health System
601 North Elm Street

P.O. BOXHP-5
Hlgh Polnt, NC 27261
(336) 878-8000
www.highpointregio~I.cbm

May 3,2007

OM0 Human Resources and Housing Branch
Attention: Carolyn Lovett
New Executive Office Building
Room 10235
Washington, DC 20503

Ms. Lovett:
I am writing to submit comments concerning the proposed change in the

processes related to CMS-R-193, the "Important Message from Medicare." The
proposed revisions will place unreasonable, additional administrative burdens on
hospitals. Using the methodology from CMS to calculate the number of hours
needed to follow the proposed processes, I estimate that our Health System will
need more than 2,100 hours per year to reach compliance. The proposal does
not increase reimbursement to hospitals to compensate for this workload. Due to
the complexity of hospital operations, compliance will be difficult in many in many
cases. Below are descriptions of just a few of those situations.
Critical care patients: While many of these patients would be able to understand
the notice, it w o ~ ~be
l d inappropriateto disturb them for this purpose. Under the
proposal, a representative can only sign if the patient is unable to understand.
Patients in isolation: As a former patient who was in isolation, I would have been
very upset by someone coming into the room merely for the purpose of providing
this notice and obtaining a signature. I would have been quite capable of
understanding the notice, so signature by my representative would not have
been compliant. Only people providing treatment should enter isolation rooms. It
is not appropriate to ask nursing or other direct care givers to deliver the notice
and obtain the signature, because they would not have enough knowledge about
the appeals process to be able to answer questions. It is also not feasible to
train hundreds of care givers to the point where they would be able to answer
questions, While the notice does provide the patient with the name and phone
number of someone to call with questions, it is not reasonable to expect that
coverage 24 hours per day, 365 days per year.
Lack of information about the patient's insurance: Not all patients provide
accurate insurance information at the time of admission. This would make it
difficult, if not impossible, to meet the 2-day requirement.

DETAILLED NOTICE OF DISCHARGE
Patient's Name:
Hospital Name:
Attending Physician*
Date Issued.

Patient ID Number:

Time:

,

This not~cegives you a detailed cxylanation of why your doctor and hospital (and/or your nlariaged
care plak if you belong to O I I ~ believe
)
you'ao longer need to be in the hospital. Your discliarge
from the hosyiral is scheduled for
. This decision i s based
on Medicare coverage policies and your doctor's inedical judgmellt,
This is not an o f i c i d Medicare decision
The decision on your appeal will comc h m your Quality Improvement Organization (QIO)
The QJO is the organization that reviews hospital care on behaIf of the hospital. Medicare and
Medicare health plans. Physicians at the QTO are available t o you, your physician, and the

hospital and will help determine the best possible plan for you.
.1

The decision to approve your dischar~efiom the hospital is based on your health condition
and tbefollowinp:

U Described here is an ex~lmtionof Medicare coverare ~oliciesland those of vour health plan if
you have one) that are used to conclude that vour hospital stay will no longer be covered:

IJ

More information is available to you:

a) If you would like a copy of the information sent to the QIO related to your discharge fiom the
hospital, please contact the QIO. [insert QIO phone number)
b) If you would like more infornlation on Medicare Coveraye policies for your hospital stay please call
1 -800-MEDICARE ( 1-500-63 3-4327), or your Health PIan nu~rlberwhicl~call be found on the back of
your Mell~berslripcard.
c) Should you need help in making these calls, please don't hesitate to ask a hospital representative for
assistance. {insert hospital phone number)

We are corfidenr x k t r ~ w uwill receive cr fair and prompt decision a d rhar
~ 7 0 . v apprupriflle
f
care

mailable fo you.

yo14 will get the he.st. cvd

MAY-09-2087
MMl

VJ

LUU l

lllu

15:45
u c .u *

-

OMB/'O I RA

202 395 5167

Patients with no representative: Some Medicare patients do not have a
representative, or may have a representative who is not an site. There is no
provision about what to do in this circumstance.
Difficulty in contacting the patient's representative: Even if the patient has a
representative that is onsite, they certainly are not here at all times. For
example, some may only visit after work. Under this proposal. hospital staff will
need to 'track down" the patient's representative to present the document and to
obtain a signature.

Another troublesome aspect of the proposal is the need to deliver a SECOND
copy of the notice prior to discharge. This repetitive delivery is just the type of
process that organizations try to eliminate as part of efforts to become more
efficient. The only people who would have the best idea of when the patient will
be discharged are the direct care givers. We do
encourage care givers to
know what insurance the patient may have, because it is truly irrelevant to patient
care. This process would require someone involved in patient care to recognize
an upcorning discharge of a Medicare patient, and to either deliver a copy of the
signed notlce or to notify someone who has that responsibility. Many of the
same problematic situations listed above will occur again at discharge. If the
admission part of the process were implemented, then the patient already has a
signed copy of the document. Providing a second copy is redundant and
unnecessary. At a minimum, this part of the proposed process should be
deleted.

a

This proposal provides minimal time for implementation. Comments must be
submitted by May 6, and compliance is expected by July 1. This does not allow
adequate time for process changes-andtraining.
It is also important to note that this proposal does nothing to improve patient
care. Isn't that the focus we should all have? Aren't there better ways to spend
scarce personnel resources?
I would be most happy to discuss any of the above point with you. My contact
information is below. Thank you for your consideration of these comments.

Carol D. Kendall, RHlA
Compliance Auditor
High Point Regional Health System
Phone: 336-878-6000, ext 2086
Email: [email protected]

P.09/30

w-m,-3m=
CLINICAL DENIAL MANAGEMENT

PO BOX 2680
HIGH POINT, NC 2726t-2680
OMB Human Resourr;es and Housing Brancn
Attention: Carolyn Lowtt
New Executive Office Building
Room 10235
Washington, DC 20503

May 3.2007

I am writing in response to tne proposed changes related to CMS-R-193, the 'Important Message from
Medicare.' 1 applaud CMS' efforts to noti* both Traditional Medicare and Medicare Advantage (MA)
beneficiaries of rheir appeal righe. UnfortunaWy, the most iniquitous issue facing Medicare beneficiaries is
that MA Plans consistently fail b notify their beneficiaries mat hospital stays are denied until after discharge.
Current MA laws do not afbrd oontmcted Providers appeal rights. In stark contrast, Traditional Medicare
affords Providers tne same appeal rights as the Beneficiary. The prowsed IM changes will not protect. nor
provide, MA Wnefciaries the same appeal rights afforded Traditional Medicare Beneficiaries until the jaws
provide both with the same appeal rights even when the MA plan is contracted witn the Provider.

The most troublesome aspect of me proposal is the need ta deliver a second copy of the notice prior ta
discharge. The most efficient organizations eliminate redundant and nm-value added processes in order to
provide the highest quality health cafe. The proposed revisions place an impossible administrative burden on
Providers. Compliance will be an absoluteiy impossible task. Providen should be allowed to focus more on
discharge planning than that the patient receives a m n d copy of the IM. The secand copy requirement
should be deleted as two noti- does not offer any Oenefn whcx$o@vefto Me patient
For example, MA plans will continue to not@ Providers and Bend~ciaries
at the bme of or after discnarge that
stays are not covered so providing the second notice prior to discharge will not protect MA beneficiaries. Until
MA p4ans are fwced to noti@ Beneficiaries in real time of denied stays or days. MA beoefiaries will continued
to be denied tneir rights under the law. Unfortunately. most M A beneficiariesare not aware of these issues.
MA Plans know me Beneficiary can not be held hancially responsible unless natified prior to services being
rendered: Z??ffefOreMA Plans wait until aRer discharge to provide adverse determination notices, effectively
holding me Provider financially responsible for the uncoveted stay. MA Benef&ries are denied a second
medical necessity review by a different Physician under current MA regulations while Traditional Medicare
beneficiaries and Providers are affordel a h t e p appeal process.
MA laws mandating advent determination notifmtions given prior to discharge will protect MA Medicare
beneficiaries. not the proposed second IM notice. Furthermore, the second notice requirement would force
Praviders l o increase thew focus and limited resources on rneetSng this requirement instead of meeting the real
heam care needs d their patients. All Medicare Beneficiariesabsolutely should have their appeal rights
provided and protected but a second n o w will not provide additional protection for Traditional Med'kare
Benefician'es and most certainly will not protect the MA Beneficiaries' appeal rights under the curmnt MA lawso

matter,
Shiryr Foster RN. MSN, MBA
Manager. Clinial Oenial Managernem
High Point R ~ e g i ~Healm
a l System
Phone: 3368784000. ext 2857
Email: [email protected]

OMB Human Resources and Housing Branch
Attention: Carolyn Lovett
New Executive Office Building, Room 10235
Washington. DC 20503
Fax: (202)395-6974

Comment on Revisions to Medicare Notices:

As the persons responsible for quality and clinical w e managanat in the Covenant Health
system in the Knoxville, Tennessee area we would like to cornmea.t on this revision:

We find it a heavy burdcn on bcilities to achieve giving this second notice, and for what
purpose? Patieats are already receiving the infomation on admission and if they do not meet
inpadent criteria, determined appropriate for discharge and they &agree, they are issued a
HNN which provides them t h e e m e days and the opportunity to appeal.

The logistics of accomplishing providing h i s information prior to discharge burdm an already
overworked staff (especially in our smaller facilities) and is one more paperwork initiative that
diverts their attention away from the quality hands on patient care we proudly provide.

The Acute Care Quality Council of Covenant Health, Knoxville, Tznnessee
Nancy Van Voorhis, RN,CPHQ Fofl Sandas Seviw Medical Center, Sevierville, TN
Judi Stindt, RN, BSN, MSN Fort Sanders Regional Medicdl Cmter, Knoxville, TN

Missy Sanford, RHIA,CPHQ Parkwest Medical Center, Knoxville, TN
Coletta Manning, RN,MHA, CPHQ Methodist Medical Center, Oak Ridge, TN
Nora Price. RN, BSN, CCM Fon Loudoun Medical Center, Lenoi~:City, TN

Tlle 2""notice would be exaemely burdensome ond costly to kilities in so many ways and
makes it difficultto address AdminisDative Simplification. The NAHAM orcanhation opposes
this requirement However, we would like to recommend instead that the language be changed to
state ihar 'Facilities should only be required to provide a mricc to the patienr whcn the
parienr/guardiandisagrees with the discme decision of the physician. Since the case managers
are already involved in their discharge planning, Jlc case managers could provide thc zndnotice
at rhat point. This would seem to be an equimble compromise and one than supports the righo of
ihe Medicare benefi-.

Respectfully submitted,

Ed Spires, CHAM
President- NAHAM

May 4,2007

Carolyn Lovert
OMB Desk OfEcer
OMB Human Resources and Housing Branch
New Executive Office Building
Room 10235
Washington. DC 20503

RE: Comment Pcriod - CMS Proposed Changes 10 rhe "Medicarc Important
Notice" Delivery
Dear Ms. Laven:
Thc National Association of Healrhcarc Access Management would lilce to voice
rheir collecrive opinion regarding the proposed change in the provision of the
notificarion to Medicare patients. We are not in favor of h e two major proposed
changcs.

One change requires the sigrature of the Medicare patient or their representative.
This was a previous requirement that CMS agreed to remove dm ro rhe impact ir
would make on hospital providers. Delivery of tho nodcc was a main on
resources in d of itself, bur having to rrack down patients who often ate not in
their rooms due to procedures, ac.,was inefficient for hospital s u f f - Bringing this
requirement back will clearly add additional cosa LO provide SUIT to perform the
follow up with a patient andlor their representarive. The NAHAM oroashrion
m o s e s this reaui-I.
The current method of p r o v i a bNotice on
admission without a requirement for a si,gnature and only providing additional
detail KOthose patients who need 10 h o w meets rhe inrent of legislation. To
require a si,onature and give the patients a copy prior to discbargc creates storage
and copying costs t h a h~ w e not been considered at all in their calculations and
will be cxncmely difficult ro manage in that a large number ol: ~hesebeneficiaries
arc not capable of signing, live in nursing homes and do not have a ,o;uardian who
can be accessed to obtain si,bnamre.
The second change is the presenting of the Notice of Non-Coverage to the
Medicare Beneficiary patients "nor more than two calendar days PRIOR to a

patids discharge." Paiient Acccss sraffdoes nor raicw parienrs' medical chms
to identifv potential discharges. Disclmrge plarming functions typically reside
wi& case managcmcnr professionals. 'llerefore, rhe issue will bc how to idenrifv
a patient's discharge "the two calendars days prior to the ~atient'sdischace"
and who will present the 2"* Imponant Message. Unlike services provided in
HHAs, SNFs. CORESand hospices, in an acute m e d i d s d n g Inany factors
dermine a patient's discharge eligibility. The question becomes, "Will acute
medial hcilities be expected to no1 discharge Medicare beneficiaries 6n thc samc
day they're identified as being eligible for discharge (somerimes based on recefpr
of rcsr renrlts in the ufiernoon) if the Norice of Non-Coverage was not presented
the previous day, tht-n-forc adding onc day to rheir LOST

2025 d Sneer. NW

Suih SO0

W>on,

DC 20036 (2021 367-11715 Fox: (202) 367-2125

Infoc.irnohom.org wmw.rahom.ofg

Baptist Health

9601 lnvrspu 630,Exit 7
L d c Rock,- 722017299
M I 202-2000

MEDICALCENTER
Little Rocb:

Centers for Medicare and Medicaid Senices
Department of Health and Human Setvices
Attention: CMS-4105-P
P.O.Box 8010
Baltimore, MD 2 1244-1850

April 23,2007

To Whom It May Concern:

t

.

'

I

I.am writing in response to the proposed rule CMS-4105-P, Medicare Program;Notification
Procedures for Hospital Discharges. I am the Director of Case Coordination at Baptist H d t h
Medical Center, an BOO+ bed community hospital located in Little Rock, Arkansas.
As a Director of Case Coordination I have been directly involved with discharge planniTlg for the

acute inpatient population for the past 15 years. Our current discharge planning practices begin at
the time of admission when patients are provided with the important Notice fiom Medicare
during patient registration Next, the admission nurses assess the patient's mat living situation
and needed resources. Ln addition, case managers intemiew 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 services. Patients and their families are involved in discharge
planning activities and are provided with choices of agencies for post acute services. Our process
also 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 administrative burden on the hospital that greatly
outweighs the benefit. CMS estimates it will take 5 minutes to deliver the generic notice and
have it signed. If a signature is required AND the patient is NOT the decision maker, it can take
an additional day to obtain the signature of the patient's decision maker. My recommendation is
to allow telephonic notification of the decision maker when the decision maker is not the patient.

Pa Baptist Health

MEDICALCENTER
Little Rock

In addition, delivery of the follow up copy of the Important Notice fiom Medicare also poses an
unnecessary financial burden on the hospital. Access to post-acute care facilities (LTACH, SNF,
Acute-Rehab, & Hospice) is not within the control of the hospital. Beds in these facilities are in
great demand and can be difficult to locate. Once a patient is accepted, the post-acute care
facility expects the patient to be transferred or the bed may be assigned to another patient. Delays
in discharge and/or transfer to post-acute facilities can result in even greater (and inappropriate)
lengths of stay in acutecare hospitals. No one wishes for the patient to miss the opportunity to
receive the appropriate level of care.
In our hospital the average LOS is 5 days. Since lengths of stay are short 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
believe 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 has received their Medicare rights information during the admission
process.

I have read that CMS estimates only 1-2% of beneficiaries wili request an expedited appeal, if
this is true, it would not be overly burdensome for hospitals to complete the detailed explanation
of Hospital Non-Coverage. I am 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 institute this rule on a temporary basis to judge the actual impact on hospitals. If

only I - 2% of patients request the expedited appeal and significant percentage of the appeals are
upheld then it is apparent that CMS has acted in the best interests of the public. If the percentage
is sipficantly higher and nearly all appeals are overturned, then it becomes apparent that this
proposal did not yield the expected results, and indeed, the increased costs (administrative and
LOS) do not justify the means.

I appreciate the role of CMS in safeguarding patient rights. We believe we must protect patient
rights while also stewarding government resources and ensuring patients do not take advantage
of an opportunity to unnecessarily extend a length of stay adding significant casts to Medicare.
Sincerely,

Baptist Health Medical Center
Little Rock, Arkansas

To Whom It May Concern:
\.

.

I am writing in response to the proposed rule CMS-4105-P, Medicare Program; Notification
Procedures for Hospital Discharges. I am the Director of Case Coordination at Baptist H d t h
Medical Center, an 800+ bed community hospital located in Little Rock, Arkansas.
As a Director of Case Coordination I have been directly involved with discharge planning for the

acute inpatient population for the past 15 years. Our cment discharge planning practices begin at
the time of admission when patients are provided with the Important Notice fiom Medicare
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 services. Patients and their farnilies are involved in discharge
planning activities and are provided with choices of agencies for post acute services. Our prows
also 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 administrative burden on the hospital that greatly
outweighs the benefit. CMS estimates it wiU take 5 minutes to deliver the geaeric notice and
have it signed. If a signature is required AND the patient is NOT the decision maker, it can take
an additional day to obtain the signature of the patient's decision maker. My recommendation is
to allow telephonic notification of the decision maker when the decision maker is not the patient.