Q&A: Readmission risk measurement
Q. What tools can be used to measure readmission risk?
A. Case managers must be familiar with all required notices and know under what circumstances to deliver a notice, such as the Hospital Issued Notice of Noncoverage (HINN). When the continued stay review shows the patient still qualifies for acute care, but the case manager finds that a diagnostic test or therapeutic service that is currently or soon will be provided is not medically necessary or related to the diagnosis, a HINN 11 can be given to the patient. Hospitals may opt not to bill for the service, but if the intention is to include it with the bill, the HINN 11 lets the patient know that he or she will be liable for the cost of the test or services, since those tests or services are not medically necessary to treat the condition for which the patient is hospitalized. The form must be signed by the patient or patient representative to indicate their understanding that the hospital plans to charge the patient for the services.
The physician does not have to agree to the denial of coverage letter, and no review is needed by the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) unless there is a specific request for one. The Medicare Administrative Contractor will sometimes review the situation if the Medicare beneficiary complains, if it is necessary to process the patient’s related claim, or if the BFCC-QIO requests a review.
If the patient decides to wait until after hospitalization to receive the services, he or she would no longer be liable for the cost. This is also true if the hospital makes the decision not to perform the procedure. The HINN 11 form remains in the patient’s chart with a notation of what occurred (i.e., the patient declined the test or service or the test or service was never done due to some other reason).
Editor’s note: For more information, see the Case Management Patient Communication Toolkit.
Need expert advice? Email your questions for consideration in the Revenue Cycle Daily Advisor. Note: We do not guarantee that all questions will be answered.