HINN, IM, and MOON: Alphabet Soup of Forms Can Be Confusing
Ensure the right form is delivered at the right time
EXECUTIVE SUMMARY
The Centers for Medicare & Medicaid Services requires hospitals to give patients an array of documents to explain their rights, their status, and any financial obligations they may incur — and it’s usually up to case managers to see that the hospital complies.
- The Medicare Outpatient Observation Notice (MOON) is the latest requirement, but the Important Message (IM) from Medicare also is required under the Medicare Conditions of Participation. In order to bill patients for services that are incurred but not covered, hospitals also must give patients a Hospital Issued Notice of Noncoverage (HINN).
- If the documents are delivered at the proper time, they could affect the hospital’s reimbursement, increase the risk of audit, and affect patients’ understanding of their rights and responsibilities.
- The entire treatment team should be aware of the documents and intentions. Education on delivering these documents should be part of case management orientation and regular education.
- Hospitals should develop a process for delivering HINNs if the need arises. Before that happens, case managers should communicate frequently with the patient and family about the next level of care.
- Patients may demand that their status be changed from observation to inpatient, but they can’t be admitted unless they meet inpatient criteria.
The Centers for Medicare & Medicaid Services (CMS) has added the Medicare Outpatient Observation Notice (MOON) to an already confusing array of documents that hospitals are required to give patients — and it’s up to case managers to make sure patients receive the right documents at the right time so the hospital stays compliant.
Now patients receiving observation services for more than 24 hours must be given the MOON to inform them of potential out-of-pocket expenses; admitted patients must receive the Important Message (IM) from Medicare, notifying them of their right to appeal their discharge; and when a patient is about to receive services that are not covered, the hospital should deliver one of the Hospital-Issued Notices of Noncoverage (HINNs).
“Case managers should be conscious of the fact that delivery of these forms is more than just another task,” says Jackie Birmingham, RN, BSN, MS, clinical leadership for naviHealth, a Cardinal Health Company based in Newton, MA, that specializes in transition management. Not following the CMS guidelines could affect the hospital’s reimbursement, increase the risk of audit, and impede the patient’s ability to understand what his or her rights are and what the hospital expects of the patient, she adds.
The only documents that CMS requires hospitals to deliver to patients are the MOON and the IM, Birmingham points out. The other notices (HINNs) are used when the circumstances arise.
“HINNs notify patients that they may get a bill if the care is denied. If patients have a financial risk and the hospital doesn’t give them a HINN, the hospital can’t bill the patient,” she says. (For more information on HINNs and how and when to deliver them, see related article in this issue.)
Delivering the IM, the MOON, or a HINN when appropriate is more than just following the rules and regulations, says Beverly Cunningham, RN, MS, consultant and partner at Oklahoma-based Case Management Concepts. “It’s doing the right thing for patients as well as keeping the hospital compliant,” she adds.
Compliance issues have become extremely complicated and confusing, adds Mindy Owen, RN, CRRN, CCM, principal owner of Phoenix Healthcare Associates in Coral Springs, FL, and senior consultant for the Center for Case Management.
“When healthcare professionals have trouble understanding the complexities of patient status and reimbursement, we cannot expect the Medicare and Medicaid population to understand it at first blush. All patients want to know how the situation is going to affect them, their healthcare, and their out-of-pocket expenses,” she adds.
The MOON has complicated delivery of the Important Message somewhat, Owen says. “They are two different documents to be delivered at two different times for two different reasons, and some people in the healthcare arena don’t realize the differences,” she adds.
The MOON is intended to notify patients receiving observation services for more than 24 hours that they may incur out-of-pocket expenses. The IM notifies admitted patients of their right to appeal their discharge.
Admitted patients should be given the IM on admission and within two days of discharge, if the length of stay is more than two days, Cunningham says. Admitted patients do not get the MOON and observation patients shouldn’t receive the IM.
“CMS has so many rules and so much compliance that it is hard to keep up with and monitor all of it,” Cunningham says.
Hospital case management leaders should educate themselves on the forms they are required to give patients and ensure that the case management staff understands the process of delivering the forms, Cunningham recommends.
“CMS has been very clear that every hospital should have a policy and formal processes regarding the delivery of IMs, HINNs, and the MOON. The policies and processes should also be part of the orientation for case managers, and everyone on the staff should be familiar with them,” Cunningham says.
Everybody on the healthcare team should know about the MOON, the IM, and each of the HINN documents and what they mean to the patient, Owen says. “The healthcare team needs to collaborate in order to successfully create and deliver these documents,” she says.
The most frequent question that Cunningham receives as she works with hospitals on compliance issues is, “What are the risks if we don’t deliver the MOON?”
“If hospitals are audited for any reason and the auditors look at the processes used to deliver the IM and the MOON, it can definitely be an issue if the hospital isn’t compliant,” says Jill Annala-Rogers, BSN, ACM, senior managing consultant for Berkeley Research Group, a consulting firm headquartered in Emeryville, CA.
That’s because Medicare Conditions of Participation require hospitals receiving Medicare funds to have a process to follow CMS rules and regulations, Owen adds.
“If an organization performing an audit on behalf of CMS finds that a hospital is not in compliance, Medicare will take action,” Owen says.
An auditor may uncover that a patient didn’t get the MOON or the IM during a routine audit, but a more likely scenario is an auditor requesting a hospital’s process for delivering the MOON, Owen says.
“It’s one thing if one or two patients didn’t receive the MOON because of extraordinary circumstance, but if a healthcare organization doesn’t have a process in place, CMS is likely to take stronger action,” she says.
CMS’ deemed status accreditation agencies — The Joint Commission, Healthcare Facilities Accreditation Program, and DNV GL — are the most likely organizations to audit hospitals for compliance with the MOON, Cunningham predicts.
“DNV has been auditing hospitals for delivery and documentation of the Important Message from Medicare (IM) and they may be interested in auditing the MOON process. If hospitals are not accredited, CMS may audit them for compliance,” she adds.
Annala-Rogers recommends that hospitals take a proactive approach and conduct their own audits of patient records to make sure that the appropriate patients are given the appropriate notices and documented in the medical record. Pull a list of all observation patients and manually review a percentage of them unless your electronic medical record has the capability of conducting an audit trail, she adds.
It’s very important for hospitals to conduct audits to ensure that the appropriate patients get the varying notices required by CMS, Annala-Rogers says.
“Auditing patient records will determine if the process is working. If the audit shows that the hospital is not compliant, the team can drill down to determine the opportunities for improvement and quickly take corrective action,” she says.
“Educating the entire team is a big piece of ensuring that the hospital remains compliant. The education should be ongoing, as it can take time to get the processes solidified as new personnel enter the team,” she says.
Make sure each document is delivered within the required time frame and that patients understand what it means, Birmingham advises. “Case managers or other personnel can give patients a piece of paper and tell them what it means — but if they cannot prove that patients understand it, the hospital isn’t compliant,” Birmingham says.
The MOON has to be verbal as well as written, in a language the patient can understand, Birmingham says. “The need for certified interpreters is likely to grow significantly,” she says.
“Case managers should make sure that patients receiving observation services are aware of their potential financial responsibilities and that they understand that patients in observation do not meet the three-midnight criteria for a skilled nursing facility stay,” Birmingham adds.
She suggests a nurse, social worker, or any clinician in the case manager role distribute the MOON. “The person presenting the MOON should be familiar with the patient and understand what the document means. This is not a role for volunteers,” she says.
Hospitals are still struggling as to what processes to use so they are compliant with CMS requirements, Annala-Rogers says. “Delivering the notices to patients takes a concerted effort between case management, the ordering physicians, and the admitting/registration department. It would be very difficult for case managers to be 100% responsible, since they are not on duty 24/7 in most hospitals,” she says.
Patients often are confused about what exactly it means to receive observation services, Annala-Rogers says. “The intent of the MOON is to give patients and family members as much information as possible about their status and a general idea of what the financial impact may be,” she says.
Parts of the MOON process are still confusing to staff and may contribute to patient confusion, Annala-Rogers adds. For example, a patient who receives observation services for 24 hours and is converted to inpatient status before the MOON notice has been delivered must still receive the MOON, even though his or her status is now “inpatient,” she says.
Hospitals are grappling with how to comply with the requirement that someone explain the MOON verbally as well as giving patients the document, Annala-Rogers says. “Some organizations are using pre-populated common clinical explanations in the MOON document explaining why patients are in observation — but there is still a struggle as to who really will take ownership of the process,” she says.
“It may be a challenge if patients ask questions and want to know exactly what their out-of-pocket costs are going to be. A member of the team knowledgeable about the out-of-pocket costs should be available to answer their questions,” she says.
The Centers for Medicare & Medicaid Services requires hospitals to give patients an array of documents to explain their rights, their status, and any financial obligations they may incur — and it’s usually up to case managers to see that the hospital complies.
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