[TazziRN]

How do you handle it when you (the nurse), the pt's caregiver (his mother), the pt's private doc (no admit privvies) all think an incomplete quad (old) with aspiration pneumonia was discharged too soon?

[cookie102]

i'm not sure.......can the pt find a doc that has adm privilages? can the private doc call the hospitalist doc? front load your nursing visits , see the patient daily for 3 or 4 days...if you get there post hosp you can always send him back, also encourage the pt mother to voice her concern while he is at the hospital, perhaps he should go to acute rehab before coming home....just thoughts

[jmgrn65]

if he is a medicaid/medicare they can refuse to be discharged and they will have i think it is 3 days, while medicare looks into it. This is a fairly new thing medicaid has put in effect in the last few months. However if it is found that the patient was ready for dc then the patient has to pay for the 3 days.

[TazziRN]

And that's a chance the pt/family cannot take, the possibility of the appeal being denied. They're already stretched past their limits with the stuff Medicare doesn't cover. The mom said she was told he would go to a SNF for a while but that changed because his Abx is q6 hrs IV. I didn't understand that one, my suspicion is that he was refused placement because of the mom. She is very very dedicated to her son and takes wonderful care of him, but she's very controlling. If things are not done her way then it's wrong, etc.

Cookie, the private doc told me that if a pt bounces back, then the hospital/hospitalist doesn't get paid for the first admission. Don't know about that one, I gotta research that.

[NRSKarenRN]

Anytime patient sent home prematurely, I call PCP, and back to the hospital they go...I do not readmit/resume care.


Remember the ABN notice?? Applies to all of healthcare.

The Advance Beneficiary Notice - General Use (ABN-G) shall be used by providers, physicians, practitioners, and suppliers for all situations where Medicare payment is expected to be denied including laboratory tests.

The Advance Beneficiary Notice - Laboratory Use (ABN-L) is specifically for use when only laboratory services are being delivered.

The Home Health Advance Beneficiary Notice (HHABN) is for homecare.

AN IMPORTANT MESSAGE FROM MEDICARE

ABOUT YOUR RIGHTS

AS A HOSPITAL INPATIENT, YOU HAVE THE RIGHT TO:

· Receive Medicare covered services. This includes medically necessary hospital services and services you may need after you are discharged, if ordered by your doctor. You have a right to know about these services, who will pay for them, and where you can get them.

· Be involved in any decisions about your hospital stay, and know who will pay for it.

· Report any concerns you have about the quality of care you receive to the Quality Improvement Organization (QIO) listed here________{Insert Name and Telephone Number of the QIO}________.



YOUR MEDICARE DISCHARGE RIGHTS

Planning For Your Discharge: During your hospital stay, the hospital staff will be working with you to prepare for your safe discharge and arrange for services you may need after you leave the hospital. When you no longer need inpatient hospital care, your doctor or the hospital staff will inform you of your planned discharge date.

If you think you are being discharged too soon:

• You can talk to the hospital staff, your doctor and your managed care plan (if you belong to one) about your concerns.

• You also have the right to an appeal, that is, a review of your case by a Quality Improvement Organization (QIO). The QIO is an outside reviewer hired by Medicare to look at your case to decide whether you are ready to leave the hospital.

• • If you want to appeal, you must contact the QIO no later than your planned discharge date and before you leave the hospital.

• • If you do this, you will not have to pay for the services you receive during the appeal (except for charges like copays and deductibles).

• If you do not appeal, but decide to stay in the hospital past your planned discharge date, you may have to pay for any services you receive after that date.

• Step by step instructions for calling the QIO and filing an appeal are on page 2.

To speak with someone at the hospital about this notice, call __________________________.




Please sign and date here to show you received this notice and understand your rights.

__________________________________________________ _________________________ ______________________
Signature of Patient or Representative Date





CMS-R-193 (approved 05/07)

STEPS TO APPEAL YOUR DISCHARGE

· STEP 1: You must contact the QIO no later than your planned discharge date and before you leave the hospital. If you do this, you will not have to pay for the services you receive during the appeal (except for charges like copays and deductibles).

o Here is the contact information for the QIO:
_____ {insert name of QIO in bold}_______________
_____{insert telephone number of QIO}___________

o You can file a request for an appeal any day of the week. Once you speak to someone or leave a message, your appeal has begun.

o Ask the hospital if you need help contacting the QIO.

o The name of this hospital is______{insert the name of the hospital and the provider ID number}__.

· STEP 2: You will receive a detailed notice from the hospital or your Medicare Advantage or other Medicare managed care plan (if you belong to one) that explains the reasons they think you are ready to be discharged.

· STEP 3: The QIO will ask for your opinion. You or your representative need to be available to speak with the QIO, if requested. You or your representative may give the QIO a written statement, but you are not required to do so.

· STEP 4: The QIO will review your medical records and other important information about your case.

· STEP 5: The QIO will notify you of its decision within 1 day after it receives all necessary information.

o If the QIO finds that you are not ready to be discharged, Medicare will continue to cover your hospital services.

o If the QIO finds you are ready to be discharged, Medicare will continue to cover your services until noon of the day after the QIO notifies you of its decision.



IF YOU MISS THE DEADLINE TO APPEAL, YOU HAVE OTHER APPEAL RIGHTS:

· You can still ask the QIO or your plan (if you belong to one) for a review of your case:
o If you have Original Medicare: Call the QIO listed above.
o If you belong to a Medicare Advantage Plan or other Medicare managed care plan: Call your plan.
· If you stay in the hospital, the hospital may charge you for any services you receive after your planned discharge date.

For more information, call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048.
__________________________________________________ _________________________

Similar appeal process available for patients with most insurances.


Hospital staff should notify Unit Manager, Discharge planner or social worker, Case Manager to get form signed and appeal started.
Homecare should notify clinical manager or Quality Improvement Manager and get HHABN formed signed by patient. Management calls QIO, not staff level person as clincal info/notes often need to be sent or verbally provided to appeals person at QIO. Appeals process is 48hr turn around.


I was called by Hospice to transfer pt to homecare who plateaued, no longer met hospice criteria and daughter had filed an appeal---will know by Friday if coming to homecare or staying in hospice.

[NRSKarenRN]

Correct, hospital often DOES NOT get paid further monies if readmitted within 7 days for same DX.

40.2.5 - Repeat Admissions
(Rev. 266, Issued 07-30-04, Effective: 01-01-04, Implementation: 01-03-05)
HO-400B

NOTE:

QIO review and the QIO's authority to deny readmissions is not limited to readmissions within 30 days. The QIO has the authority to deny the second admission to the same hospital no matter how many days elapsed since the patient's discharge.

When a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital, and is readmitted to the same acute care PPS hospital on the same day for symptoms related to, or for evaluation and management of, the prior stay’s medical condition, hospitals shall adjust the original claim generated by the original stay by combining the original and subsequent stay onto a single claim.

Services rendered by other entities during a combined stay must be paid by the acute care PPS hospital. The acute care PPS hospital is responsible for the other entity’s services per common Medicare practice.

NOTE:

Medicare does not reimburse other entities for services performed during two inpatient acute care PPS stays that are combined onto a single claim. However, the other entity’s services may be considered and billed as covered services, when appropriate, by the acute care PPS hospital.

When a patient is discharged/transferred from an acute care PPS hospital and is readmitted to the same acute care PPS hospital on the same day for symptoms unrelated to, and/or not for evaluation and management of, the prior stay’s medical condition,

hospitals shall place condition code (CC) B4 on the claim that contains an admission date equal to the prior admissions discharge date.

http://www.worh.org/pdf_etc/Dec2/readmits.pdf

Medicare DOES NOT pay for IVAB in the home; however, if there is secondary insurance, often they will pay for drug cost and supplies as cheaper alternative to inpatient stay. Medicare WILL pay for RN to administer/teach family----can not have 2 MEdicare agencies billing for RN care at same time.

What is done in my area is infusion company doesn't bill Medicare anything for RN to teach family, bills secondary for drugs/supply costs....first home care agency stays in when patient has wound care or significant homecare needs. If no secondary insurance, only alternative is SNF stay for IVAB coverage or go on PO meds if SNF refused by patient caregiver---choice Patient/ Caregiver makes.

[TazziRN]

Ahhhhh......methinks I need to go back and read the form more carefully....I thought it said that if the appeal was denied, the pt would have to pay for the time if the decision had not been made before the date of intended discharge, like if the pt decided to appeal the evening before anticipated D/C.

I knew that MC doesn't pay for the meds, his secondary is picking that up.

Why is there an issue about paying for readmissions? Is it because the pt was D/C'd too soon?

I knew that if a pt was admitted and then transferred out within 3 days, the first facility doesn't get paid for the inpt portion, just the ER portion....which does not make sense to me. Sometimes the inability to transfer is beyond the first facility's control....bed status, etc.