Regulatory Bulletins

Bulletin 04 – CMS Revisions to Requirements for Discharge Planning for Hospitals

Versalus Health’s Comments on CMS’ Revisions to Requirements for Discharge Planning for Hospitals

On September 30, 2019, the Centers for Medicare & Medicaid Services (CMS) published a new Final Rule, Revisions to Discharge Planning Requirements (CMS-3317-F). The goal of these changes is to attempt to further empower and involve patients and their families in the discharge planning process by providing access to information necessary to make informed decisions about their post-acute care (PAC) services and to reduce the potential for re-hospitalization. This is accomplished largely through mandating access to information about discharge planning needs and the resources available to the patient. The Final Rule modifies the Medicare Conditions of Participation (CoP) to implement a discharge planning process that focuses on the patient’s goals and takes into account post-acute care data on quality measures.  

 “This final rule also implements discharge planning requirements which will give patients and their families access to information that will help them to make informed decisions about their post-acute care, while addressing their goals of care and treatment preferences, which may ultimately reduce their chances of being re-hospitalized.” (84 FR 51836) 

 In the Final Rule, CMS identified that hospitals are already performing most of the revised discharge planning requirements and would continue to require hospitals to regularly assess their discharge planning process. 

 “We therefore are finalizing a provision at § 482.43(a)(7) (as originally proposed at § 482.43(c)(10)) that would require a hospital (or a CAH) to assess their discharge planning processes on a regular basis, which would include ongoing, periodic review of representative sample of discharge plans, including those patients who were readmitted within 30 days of a previous admission, to ensure that the plans are responsive to patient post-discharge needs.” (84 FR 51849) 

 Discharge planning is an important tool in a patient’s successful transition from the hospital to a post-acute care setting. The revisions in the Final Rule require that discharge planning evaluations be discussed with the patient (or patient representative) and placed in the patient’s medical record for the development of the discharge plan. In addition, hospitals must re-evaluate the patient’s condition and determine if any changes in patient condition require modifications to the plan. Also, the Final Rule requires that appropriate arrangements are made to avoid delays in discharge.  

 “…the hospital must identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning. The hospital must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, the patient’s representative, or patient’s physician.” (84 FR 51854) 

Under the revised Conditions of Participation, hospitals must provide patients with a list of available facilities within the appropriate geographic area, regardless of bed availability, and data on quality measure for those facilities. Central to the new regulation is the concept that the patient knows all the options, and not be guided by a “preferred” list of facilities developed by the hospital.  

“The hospital, as part of the discharge planning process, must inform the patient or the patient’s representative of their freedom to choose among participating Medicare providers and suppliers of post-discharge services and must, when possible, respect the patient’s or the patient’s representative’s goals of care and treatment preferences, as well as other preferences they express. The hospital must not specify or otherwise limit the qualified providers or suppliers that are available to the patient. We do encourage hospitals to provide any information regarding PAC providers that provide services that meet the needs of the patient. Hospitals must not develop preferred lists of providers.” [bold added by author] (84 FR 51861) 

 

Many hospitals are concerned about the additional administrative burden and potential for post-acute care placement delays that could result. Interestingly, these concerns are similar to those expressed in November 2006 when CMS published the Final Rule, CMS-4104-F, with revisions to how hospitals delivered the Medicare Important Message.  

 

Hospital Operational Impact and Imperative:  

In order to be compliant with the new Discharge Planning requirements in the CoP’s, hospitals must provide patients and their families access to information to help them make informed decisions about post-acute care (PAC) services. When a patient desires to be discharged to a PAC facility without an available bed, hospitals should be prepared to begin the Hospital-Issued Notice of Non-coverage (HINN) process that ensures patients have the appropriate information to make the right care and financial decisions. As required by Section 1154 of the Social Security Act, a hospital must provide a HINN, to any beneficiary that expresses dissatisfaction with an impending hospital discharge. The purpose of the HINN is to inform the patient of any potential financial liability regarding hospital services that Medicare does not cover. CMS has identified 4 types of HINN: 

 

    • HINN-10, also known as the Notice of Hospital Requested Review (HRR), should be issued by hospitals to beneficiaries whenever a hospital requests Quality Improvement Organization (QIO) review of a discharge decision without physician concurrence. HINN 10 may be used for Original Medicare beneficiaries or Medicare Advantage enrollees. 
    • HINN-11, which is used for noncovered items or services provided during an otherwise covered stay. 
    • HINN-12 should be used in association with the Hospital Discharge Appeal Notices to inform beneficiaries of their potential financial liability for a noncovered continued stay. 
    • The Preadmission/Admission HINN, used prior to an entirely noncovered stay, is also known as HINN 1. 

 

It is important to work with your discharge planning team to understand that quickly and appropriately pursuing the HINN-12 process allows the hospital to act on behalf of the beneficiary’s rights when following the revised discharge planning rules identified under the Medicare Conditions of Participation. The HINN-12, is issued at the end of a hospital stay when a discharge order is written but the beneficiary chooses to remain in the hospital and is used in association with the Hospital Discharge Appeal Notice. The HINN-12 should be delivered at the time an available post-acute bed is identified and declined. Avoiding a delay in the delivery of the HINN-12 will prevent unnecessarily prolonged length of stays.  

 

Operational Recommendation:  

Standardize a HINN-12 process to proactively position the hospital to act quickly on behalf of beneficiary rights: 

  • Appoint a discharge planner as an expedited appeal beneficiary advocate expert. 
  • Start with the Important Message to ensure that the hospital is compliant with Federal Regulations and a beneficiary advocate.  
  • Provide a list of post-acute care (PAC) providers including quality data and without reference to “preferred status.” 
  • Avoid any delay in delivering the HINN-12 after an available bed is identified. Explain the HINN-12 process so that the beneficiary understands that the hospital is doing all it can to preserve the beneficiary’s rights of appeal under Medicare.  
  • Avoid any delay in providing the material for an expedited QIO appeal. 

Note: On January 7, 2020, the Office of Management and Budget (OMB) renewed the Important Message (IM) and the Detailed Notice of Discharge (DND). Hospitals are required to use the new IM and DND beginning April 1, 2020.  Both the previous and new versions of the notices are acceptable for use through March 31, 2020 and can be found here: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices. 

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