HINN: A powerful tool in Medicare discharges
Discharge planners often miss the opportunity
What do you do when a Medicare patient is medically able to be discharged, but refuses? The Medicare Hospital Initiated Notice of Non-Coverage (HINN) is a powerful tool for hospital staff in dealing with patients who are not cooperating with their discharge plan.
HINN states that hospitals may begin charging patients beginning at 12:01 on the third day after the notice is given, which may convince patients to get their affairs in order and follow the discharge plan.
The trouble is, many discharge planners, case managers, and utilization coordinators are reluctant to use the HINN for many reasons. But letting a patient's family abuse the hospital is wrong, says consultant Elgin K. Kennedy, MD, of San Mateo, CA.
Why the reluctance?
Not wanting to get involved in such sticky issues, physicians and hospital staff count on the UR coordinators to issue the notice and deal with the consequences. If handled properly, they can use HINN without offending physicians and without alienating patients too much. Kennedy explains how to overcome reluctance to use the HINN, when to use it, and how to present it to patients and doctors in a diplomatic way.
The perceived roadblocks to using the HINN are many, but none should keep administrators from using this powerful money-saving tool. Listed below are common reasons for not employing the HINN, followed by tips for overcoming these barriers:
* It's a gamble that could backfire. The patient might just leave on the date of discharge, but if the HINN is issued, he or she might view the notice as giving him or her an extra couple of days in the hospital. True enough, Kennedy says, so play the odds: If you believe there is a greater than 50% chance that the patient won't leave the next day, issue the HINN. That way, the patient must leave the day after tomorrow to avoid a hospital bill. Note, too, that the notice specifies that the hospital may start billing at 12:01 a.m. on the third day after the notice is issued. That means only two grace days, not three, as many administrators mistakenly believe. (See how model letter creates confusion, p. 42.)
* Foot dragging. Hospital physician advisors drag their feet in reviewing the case and then approving discussions with the attending physician. If this is the case, Kennedy advises bypassing the physician advisor and going straight to the attending physician, since no rules state that the advisor must be consulted on whether to discharge the patient.
* Physician reluctance. Attending physicians are reluctant to give the notice. Approach the physician correctly and you will encounter less resistance, Kennedy says. Keep your telephone call brief and to the point. Emphasize that the patient is medically stable, that he or she meets all of the state's peer review organization (PRO) discharge screens, but the patient nonetheless appears to be reluctant to leave. Mention that the physician's name will not appear on the notice, though the notice does state that the physician agrees with the decision.
Also make it clear that the notice will be revoked immediately should the patient's condition change. If the physician still refuses to give permission to issue the notice, you may appeal to your state PRO, but this route means extra delays of as much as two working days while the PRO gives an answer.
* Raising red flags. Some hospital administrators believe that issuing the HINN will be a red flag for PRO chart reviewers because it is a sign that the discharge planning process has broken down. Obviously, if the admission was inappropriate or there has been a quality problem, the hospital is better off not giving the notice. But be aware that issuing the notice does not automatically trigger a PRO review. In fact, a review is rare unless the patient asks for one. Most patients do not bother going through the process, Kennedy says.
* Creating image problems. Issuing the HINN will make the utilization review, case management, and/or discharge planning departments look bad. After all, issuing the HINN is a last-ditch effort. It means all other attempts to convince the patient and his or her family that the discharge plan is best have failed. Some patients, however, are simply unreasonable or want to abuse the system and will never be convinced. This is no fault of the hospitals.
* Bad PR for hospital. Giving the notice is bad public relations. True, Kennedy concedes, but this negative must be weighed against the high cost of keeping such patients in the hospital.
* Messenger's job is disagreeable. Giving the notice is unpleasant and time-consuming, Kennedy says. Approach the patient sympathetically, but be brief and to the point. State that you are sorry to issue the notice, but Medicare rules state that you must. Offer assistance from a social worker or discharge planner. You might also point out that the grace period is in fact quite generous, because managed care patients are required to leave that same day or the next day to avoid being charged.
Who is a candidate for HINN?
Patients and their families have all sorts of reasons for not wanting to cooperate with the discharge plan. They may simply say the patient does not feel well enough or strong enough. They may be afraid. They may be unwilling to transfer to a nursing home. The patient's family may not be helpful in locating a nursing home. They may say that they have not found just the right home care attendant, or that the home is not ready for the patient to come back. In any case, none of these reasons are valid and constitute an abuse of the system, Kennedy says.
The only legitimate reason for not pursuing the HINN option is if you know the patient is determined to stay and is also destitute and has no attachable assets. In such a case, the hospital will only incur more expense by taking the time to issue the HINN and will not get anything back for its efforts.
Eliminating the two-day grace period
If a utilization management professional becomes convinced that using the HINN can save the hospital money, he or she may want to go a step further and use the Advanced Continued Stay HINN. According to the Baltimore-based Health Care Financing Administration's PRO manual, if a hospital is able to determine in advance that the beneficiary will not require acute inpatient hospital care as of a certain date, it may give the notice of non-coverage in advance of that date -- but ordinarily no earlier than ten days before the first non-covered day.
In other words, you can eliminate the two grace days if the timing of the HINN issuance is accurate and you can predict in advance which patients will be stable enough to be transferred.
There are cautions to using the advance notice. Utilization management professionals may encounter the same problems in getting physician and patient cooperation with Advanced Continued Stay HINN as they encounter when issuing a regular HINN. If the patient vomits, develops a fever, or develops other complications, the Advanced Continued Stay HINN must be revoked, and the entire HINN process must be started up again when the patient is medically stable. The HINN must also be revoked if a skilled-nursing facility bed is no longer available or there is some other problem in transferring the patient. Obviously, physicians will not like dealing with a continuous stream of HINNs. So, utilization management professionals must carefully choose how they use the Advanced Continued Stay HINN and the HINN. *
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