Monitoring of Hospital-Issued Notice of Non-coverage –

7025 - Monitoring of Hospital-Issued Notice of Non-coverage – (Rev. 4, 07-18-03) A. Purpose Monitor the content of the HINN and the accuracy of the hospital's determination (see Hospital Manual, §414.5).  Upon a beneficiary's or a hospital's request for review, determine whether the HINN is appropriate and accurate (See §§7005 and 7020).  For HINNs (e.g., admission) that are issued and no request for review is made, ensure no less than every 6 months a year that: • The hospital followed the appropriate process; • The content of the notice is accurate/appropriate; and • The hospital's decision to issue the notice is correct.  Monitor the hospital to ensure that it is issuing the Hospital Notice to Beneficiary of QIO Review of Need for Continued Hospitalization timely to the beneficiary when your review is requested (See Hospital Manual, §414.11, Exhibit 10). B. Ongoing Monitoring  Case Selection -- Conduct review of cases as follows: • Cases selected monthly by CMS from the processed claims data where the hospital has issued a HINN and there is beneficiary’s liability for payment. • Cases you have selected (no more than 6 months basis) by using the copy of the (preadmission, admission, or continued-stay) HINN submitted to you by the facility within 3 working days of the HINN issuance. NOTE: Hospitals are required to submit a bill for all inpatient stays, including those for which no payment can be made. Although no monies are involved with "No-pay bills," a claim is required because hospitalization could extend a Medicare beneficiary's benefit period (see Hospital Manual, §411).  Timing of Review -- For all cases selected for review, request medical records and complete review according to the timeframes for retrospective review. Reconcile the CMS selected claims data with copies of the HINN you received to ensure that the hospital is notifying you of all notices issued. If you identify a hospital's failure to submit no-pay claims to the intermediary, work with the intermediary to establish a procedure to address/resolve the hospital's billing problem. The procedure should specify that if after a reasonable period of time (e.g., 6 months or longer) you are unable to reconcile the information between submission of the HINN and the claim data, you notify the intermediary and the hospital of the problem. The procedure must delineate the party (you or the intermediary) who is responsible for sending the hospital formal notification of noncompliance with the billing instructions (See Hospital Manual, §411). If the hospital does not submit a claim to the intermediary (after the specified period of time), notify the respective CMS Regional Office (RO) to take necessary action under its authority to bring the hospital into compliance with program requirements.  Review Process -- For cases involving preadmission, admission, and continued- stay notices, review: • All notices received to determine whether the language content of the HINN met the requirements (See Hospital Manual, §414.5); • HINN cases selected by you (from “all notices“ received) to determine the appropriateness of the notice (i.e., the care was not covered from the point determined by the hospital and the content of the notice met the requirements of §414.5 of the Hospital Manual); • All cases selected by CMS where the beneficiary is liable for charges for services furnished after notification (See §4230.D). Review these cases to ensure that the beneficiary is not held liable for charges covered by Medicare as specified at §7025; • All cases involving admission and continued-stay notices identified from processed claims data where the hospital failed to send you a copy. Examine these cases to ensure that abuse is not involved (e.g., a hospital is withholding copies of inaccurate notices to avoid QIO review); • All cases where the medical information you used for approval was received by telephone and the HINN issued significantly differs from the claim submitted to the intermediary, or where the past history of the facility indicates poor compliance; and • All cases where you received a beneficiary complaint that was unrelated to the issuance of a hospital notice. However, if during your review evidence is found that a HINN was issued, you should review the HINN as well as the complaint issue (e.g., cases received under Hospital Payment Monitoring Program (HPMP)). NOTE: For all continued-stay cases, determine the medical necessity and appropriateness of the admission (see §7005.B.2).  HINN in the Outpatient Setting -- Review notices issued to Medicare outpatients undergoing surgery if the notice relates to denial of admission to the hospital. Review these notices if the beneficiary or his/her representative bring the issue to your attention or if the case is already under review.  HINN Related to Exclusion and Coverage Issues -- The intermediary is responsible for medical review of claims that involve general exclusion and coverage issues, and review of HINNs associated with those denials. If the intermediary refers a coverage issue case (e.g., dental or cosmetic surgery) to you because a medical necessity review/determination is needed, then review the case and the HINN, if applicable. C. Notification of QIO Determination Upon completion of notice review, take the following actions:  Admission/Preadmission Notice of Non-coverage • Issue a notice to all affected parties indicating either that the admission was non-covered (i.e., the hospital was correct in issuing the notice) or that the Medicare program would have covered the admission (i.e., the hospital notice was not issued correctly). • If Medicare should have covered the admission and the beneficiary was admitted after receipt of notice, notify the hospital, attending physician, beneficiary, and intermediary that the notice is invalid. Instruct the hospital to refund any monies collected from the beneficiary except for the applicable coinsurance and deductible amounts, personal convenience services, and items not covered by Medicare. The hospital may then submit a claim for Medicare payment, if appropriate.  Continued-stay HINN • For PPS cases, if there is a Diagnosis Related Group (DRG) change as a result of DRG validation, issue the notice; • If you concur with the hospital that continued inpatient hospital care was not necessary from the point determined by the hospital, issue the denial notice and inform the affected parties that you concur with the hospital's decision (See §§7100-7115); • If you determine that the hospital level of care ended earlier than determined by the hospital and additional days of care or costs are denied (non-PPS cases or PPS outlier cases), issue the denial notice (See §§7100- 7115); • If you determine that the admission was not medically necessary or appropriate, issue an admission denial and determine which party is liable; or • If you determine that the hospital's finding is invalid (i.e., the beneficiary required continued inpatient care) and the beneficiary received services for which he/she could be charged, notify the hospital, attending physician, intermediary, and beneficiary. These HINNs are considered inappropriate (See subsection D). Specify in your notice that the charges were invalid and, to the extent collected, must be refunded by the hospital to the beneficiary. The hospital may submit the claim for Medicare payment. NOTE: Except for those cases reviewed at the beneficiary's or hospital's request, you do not have to issue a denial notice in cases where you agree with the HINN and the beneficiary was not liable for the charges. D. Inappropriate HINN An inappropriately issued HINN would be any case where:  The hospital's finding is invalid (e.g., where the admission was covered (See subsection C.1), and where continued acute care was medically necessary (See subsection C.2));  The content of the notice is not in compliance with §414.5 of the Hospital Manual;  The patient was charged for hospital services without a notice;  The patient requires SNF care and there was no available SNF bed (See §7005);  A continued-stay HINN is issued without your concurrence or the concurrence of the attending physician (except in cases where the level of care changes from SNF swing bed services to NF); and  The beneficiary did not receive written notice when discharged from acute care and admitted to SNF or NF swing bed services. NOTE: In cases involving an admission HINN where you determine that the beneficiary's condition changed from non-acute to acute, assign a deemed date of admission. Because you agree that the HINN was not issued in error, do not count the case against the hospital as long as the hospital did not charge the beneficiary for the covered acute inpatient services. E. Corrective Action Take corrective action immediately. If, during the course of your review, you detect that a particular hospital has issued an inappropriate notice, determine whether:  The hospital issued a notice of non-coverage that could result in inappropriate collection of monies from a beneficiary. For example: • In a beneficiary request for an immediate review of a HINN with attending physician concurrence, a hospital notice indicates that if you review the case and deny the care, the beneficiary will be liable beginning the third day after receipt of the notice; or • A beneficiary complained that the hospital advised him/her that the care was non-covered, but a written notice was never issued.  The hospital issued a notice that the admission or continued inpatient hospital care was non-covered, but a copy was not submitted to you and the case was identified from the processed claim data (See §7025.B.1); or  The notices are improper but do not transfer liability for payment to the beneficiary (e.g., the HINN states that Medicare made the decision), and the hospital refuses to change its notices to bring them into conformance with requirements. Advise the hospital that issuing invalid notices that result in an improper collection of monies from beneficiaries is a violation of the hospital's Medicare provider agreement. The hospital must make immediate restitution except for the applicable deductible and coinsurance amounts, and if applicable, report the refund (proof of payment) to you and the intermediary. The hospital's failure to correct its notices and bring them into conformance with the requirements will lead to referral of the hospital to the regional Office of Investigations, Office of Inspector General, Health & Human Services, for enforcement under §1886(f)(2)(B) of the Act. Other examples of inappropriate notices and corrective actions include, but are not limited to:  Cases, in which you initially concurred with the hospital on the issuance of the notices but upon reconsideration or retrospective validation review (See §7005.B.2) it is determined that in two or more cases the notices should not have been given (e.g., pertinent information on the cases was not provided), perform the notice review of cases where the attending physician and hospital do not concur by requiring medical records on every request for review; and  Cases, in which a pattern of abuse is identified (e.g., where you determine that inpatient care was medically necessary but a notice of non-coverage was given) that meets the definition of a substantial violation in a substantial number of cases or a gross and flagrant violation, develop a sanction recommendation in accordance with §§9000-9070.