MAY , 1986 
-#P09..86..00051
CONTROL 
MEDICARE 
PATIENT DENIAL NOTICES 
HOW PA T/ENTS ARE NOT/FlED ABOUT TERM/NA T/ON OF A HOSPITAL STA 
June 12, 1985

Mr. Bert Smith

3 Payne Boulevard 
Evanston , Proland  00001 
Dear Mr. Smith: 
The Nowhere General Hospital has reviewed the medical ser
vices you have received for the treatment of the ulcerations 
of your left 
leg from June 1, 1985 through June 11, 1985. 
Your attending physician has been advised that beginning 
June 13, 1985 further treatment of the ulcerations of your

left leg could be safely rendered  in  another setting. You 
should  discuss  with your attending physician other arrange
ments for any further health care you may require. 
You  will  not be responsible for payment of the services 
which are rendered by  this  hospital from June 13, 1985 
through June 14  1985  except for payment of  deductible 
coinsurance  normally
, or any convenience services or  items 
not covered by Medicare. If 
you  decide  to stay in the
hospital, you will be  responsible  for payment...  Offi ce of the 
Inspector General 
The mission of the Office of the Inspector General (OIG) is to promote the
efficiency, effectiveness and integrity of programs in the United States 
Department of Health and Human Services (HHS). It does this by developing 
abuse. 
methods to detect and prevent fraud, waste and  Created by statute 
1976 , the Inspector General keeps both the Secretary and the Congress fully and
currently informed about programs or management problems and recommends 
action. 
corrective  The OIG performs its mission by conducting audits,
investigations and inspections with approximately 1 200 staff strategically 
located around the country. 
Offi ce of  and Inspections 
Ana lys i s 
This report is produced by the Office of Analysis and Inspections (OAI), one of 
offices within the OIG. 
the three major  The other two are the Office of Audit 
typically,
and the Office of Investigations. OAI conducts inspections which are 
short-term studies designed to determi ne program effectiveness , effi ciency and 
vulnerability to fraud or abuse. 
Report 
Th is 
Entitled " 
the exteMnetd itcoar ew Phaitcihe nitn aDpenpiraolp Nroiatitece dse" ntihails  nreoptoircte swa ws eprreep bareeidn tgo  isdsetueerdmi tnoe 
this 
hospitalized patients, to analyze impact of  problem and to identify 
correct i ve act i 
on s. 
TInhes psetcutidoyn sw as Rpreegpiaroend  IbyX .t heP aRretgiicoinpaalt iInngsp ienct otrh Giesn eprraolj ,e cOtf fwiecer eo ft hAena lfoyslliosw ainngd 
peop 1 e 
San Franci sco Regi 

Thomas A. Purv is (Project Leader)

Rita M. Lutticken

Headquarters Offi ce 
Penni St. Hilaire
 TABLE OF CONTENTS

Page 
Major Fi nd i ngs 
Introduction 
Background 
Purpose  and Approach 
Findings 
Conclusions 
Recommendat ions
 MAJOR FINDINGS 
BENEFICIARIES ARE ADVERSELY AFFECTED BY CURRENT DENIAL NOTICE

PROCEDURES 
They are frequent 1 y confu sed and upset by rece i pt of den i a 1 not ices. 
Informal discussion , not formal denial notice, is the usual prelude to 
premature di scharge. 
Many complaints concern inadequate discharge planning and follow-up 
care. 
ll decisions 
They do not challenge " authority figure made by physicians 
so. 
or hospital officials; they are not aware they have the right to do 
PRO REVIEW IS NOT COMPLETE

PROs conduct reviews which are not adequately targeted on patient 
discharge or discharge planning. 
PROs feel that the newly-issued HCFA instructions concerning review of
notices are  but do not help them identify 
adequate for content 
premature di scharge cases. 
CONSUMER ORGANIZATIONS URGE STRONGER ROLE, MORE EDUCATION

There is a major lack of quality educational materials about PPS 
coverage. Beneficiaries and 
sophisticated providers alike indicate a 
high level of misconception. 
Consumer representatives have the potential for more active roles on 
Peer Review Organizations boards. 
HOSPITAL NOTICES LACK ADEQUATE SAFEGUARDS

are  ve  to 
Hospi ta 1 s  tak i ng correct i  act i on  reduce the i nc i dence 
inappropriate written denial notices but

incorrect 
Until recently, frequently issued notices that contained 
or misleading information and 
Are still routinely discharging patients without informing them of

their rights. 
 INTRODUCTION 
BACKGROUND 
are routinely 
Most Medicare patients  discharged from the hospital when their 
physician decides that they no longer need acute care. The physician conveys 
this decision verbally to the patient and the patient leaves, usually the next
day. 
For  discharges, no 
such routine  formal written notification is given. 
Sometimes, however, a patient or a patient' s family indicates a desire to stay 
necessary. 
in the hospital beyond the time that acute care is deemed  In such 
cases the hospital itself , acting though its utilization review (UR) committee, 
can deci de to termi nate an acute care stay. When the hospital deci des 
discharge the patient 
, the hospital is required to issue a written notice to the
patient. This is called a " denial notice.  The attending physician mayor may 
notice. 
not concur in the hospital' s decision to issue a denial  Only a small 
percentage of patients, however, receive formal , written denial notices. 
regulations. 
The provisions for issuing denial notices are outlined in the PPS 
appeals. 
These regul at ions contai n a number of procedural safeguards and  The 
content of the notice must spell out these safeguards by specifically informing 
ci ary that 
the benefi 
It is 
the 
the hospital'  determination with  concurrence of the 
attending physician or the Peer Review Organization (PRO) that the 
beneficiary no longer requires inpatient hospital care; 
charges for 
2 )	 The patient will be liable for the hospital. s customary 
after 
continued stay, beginning with the third day  receipt of the 
notice; 
3 )	 If the patient remains in the hospital after he/she becomes liable, the 
PRO will make a formal determination of the medical necessity and 
appropriateness of the hospitalization; 
This formal determination is subject to a reconsideration by the PRO at

the request of the patient, hospital or attending physician; and

5 )	 Any monies for continued stay collected by the hospital will be
refunded by the hospital , if a finding is subsequently made that the 
patient did require continued inpatient hospital care. 
In cases where the attending physician concurs with the hospital that continued 
acute care is not necessary, the hospi tal may issue the noti ce di rectly. If the 
attending physician disagrees with the hospital.  discharge decision  the 
hospital must obtain the approval of its decision from the PRO. The notice 
therefore must indicate that the PRO has reviewed the case and agrees with the 
hospital. 
decision of the  In the case where the patient actually stays in the 
hospital after receipt of the notice, PRO review is mandatory. The PRO reviews 
at least a 10 percent sample of cases where the patient had received the notice
and left before incurring charges. Corrective  all 
action must be initiated for  cases where a PRO determines that notices have been issued inappropriately. 
These actions include education, intensified review, and sanctions. 
In addition to the medical review of a hospital' s decision to issue a denial
notice, the  of this notice. 
PROs also  content  Under the 
must review the 
requirements of HCFA Transmittal 1M 85-3 issued in May 1985, PROs must insure 
that the notice is (1) in conformity with PPS regulatory requirements and (2) 
does not contain statements which allege that the decision to discharge the 
patient was made by a party other than the hospital or that the number of days 
is fixed. 
allowed" by Medicare for a certain DRG category  The PROs secure 
samples of model denial notices from all hospitals in their area and review them 
for conformity to the requirements. The PROs not only provide detailed comments 
ttoo  the hospitals concerning irregularities ini st he notices, but also monitor them
insure that correct i on of the not ices  imp 1 emented. After the in 
i t i a 1 
review of all notices issued by all hospitals, the PROs must initiate an ongoing 
notices. 
process for reviewing a monthly random sample of  These reviews are 
currently underway. 
PURPOSE AND APPROACH

The purpose of th  i on is  ne (1) the 
is inspect  to determi  extent of the prob 1 em 
hospitals issuing 
related to  inappropriate or improper denial of coverage 
(2) the 
notices to Medicare beneficiaries;  impact of improper denials
beneficiaries and the extent to which they contribute to premature patient 
discharge; (3) the role played by hospitals and by physicians in issuing formal 
or informal denial notices; (4) whether recent HCFA instructions and subsequent 
PRO reviews of notices are bringing about adequate corrective action; and (5)
the role of 
consumer groups and senior citizen organizations in beneficiary
educat i on and advocacy. 
Representatives of 48 PROs were contacted, either in person or by telephone.
addition , a number of interviews were conducted with hospital staffs and 
acsistoizceiantiso nass   wbeelnle afisc iwariyt ha dinvodcivatied ugarol ubpesn, perfoicviiadreiress .o fF iseelrdv iwcoersk  tfoo rs etnhioisr 
inspection was done during the period of August to October 1985. 
This  into the 
inspection is closely tied  inspection of premature patient
discharge now being carried out by the Office of Analysis and Inspections
Region V.  , "

FINDINGS 
Until Recently Inappropriate Patient Denial Notices Were Common

The PROs reported that prior to the May 1985 issuance of HCFA review and 
corrective action instructions, hospitals did not use a common format for 
regulatory 
issuing patient denial notices. Failure to conform to the PPS 
requirements was widespread. Some of the more common deficiencies were:

restricts the 
Indicating that Medicare  number of days a patient can 
stay in the hospital;

hospital itself 
Indicating that Medicare or the PRO, rather than the 
determi nes when a patient can be di scharged from acute care; 
their  or 
Failing to properly notify patients of  appeal rights 
furn i sh the pat i ent wi th the name and phone number of the PRO so that 
an appeal could be made if necessary; 
Failing to include the actual date the patient becomes liable for 
inpatient charges (starting the third day after patient receipt of the 
not ice); and 
Failing to include a statement that any monies collected by the 
hospital will be refunded if a finding is subsequently made that the 
patient required continued inpatient care. 
Nei ther HCF A nor the PROs, however  conducted a systemat i c survey to 
actually measure the extent of the problem or provide a breakdown of the 
1985. 
However the 
specific kinds of deficiencies that existed prior to May 
majority of PROs contacted during this inspection were aware that problems 
relating to the issuance of formal patient denial letters did indeed exist. 
Seven of the PROs, in fact, described it as a major problem, while only nine 
all. 
stated that it was not a problem at 
Hospitals are Taking Corrective Action

In May 1985 HCF A issued instruct i on 1M 85-3 "PRO Man itori ng of Hospital 
1I This 
Notices for Denial of Continued Stay. instruction set out steps for 
PROs to follow to review all notices issued by hospitals , provide comments 
to the hospitals to correct those that are not appropriate, and set up a 
corrected. 
monitoring system to insure that these deficiencies are 
Nearly all of the PROs contacted felt that the recent HCFA instructions have 
resulted in appropriate action to correct problems identified with formal 
written patient notices. As one PRO noted  we caught a lot of problems 
with the notices when we did the review of all of our hospitals. We are 
correctly, in 
sending these back and telling the hospitals to do the notices 
regulations. 
conformity with the HCFA  We anticipate no trouble in getting 
the corrections made.  As the following chart shows, of the 41 PROs who responded to this question

most now report an improvement in the written notification process:

Number of Sample

Comment  PRO Respondi ng 
Notices were a major problem, now corrected

Not ices were a mi nor prob 1 em , now corrected 
Some improvement noted , but st 
ill a mi nor prob 1 em 
Not ices were never a prob 1 em at all 
Total Responding

Receipt of Denial Notices Upsets and Confuses Patients

Hospital UR coordinators and PRO staff  as well as senior advocate 
i ents are frequently 
organi zatl lio ns, report that pat  upset and often confused 
by receipt of denial notices. References to II responsibility for payment of
services and "formal determination of medical necessity and 
appropriateness " can be disturbing to patients, especially those believing
ftheeeyl  sthhoautl dt hbee  allowed to remain int oth ec lhaorsipfiyt al. Moreover, respondents
notices do little  what is now a patient'
responsibi  ity under PPS. 
Further confusion results from patients receiving 
after 
they have been discharged, or in some cases notices going to
fnoaticems  ily members after the patient has died. HCFA has tried to word the
notice clearly and simply, but  this 
respondents in  inspection say 
improvements can be made. 
PROs Report No Problem Implementing HCFA Instruction IM 85

difficulties in 
None of the PROs contacted reported any  implementing the 
HCFA i nstructi ons. The PROs feel that the acti on steps requi red by 1M 85
do deal adequately with the problems of written notices. liThe instructions 
required a lot more work from us , but we had no problem in implementing
typical response. 
them " was a  A few PROs reported some minor difficulties 
iins  getting hospitals to understand the role of the PRO; namely, that the PRO
only involved in the initial denial notification process when the 
hospital and physician disagree. 
The American Medical Peer Review Association (AMPRA) in a letter to HCFA 
dated July 29, 1985 raised several concerns about the HCFA procedures. The
most  with the 
important of these dealt  need for clarification of the 
authority of hospitals to issue, and PROs to review, pre-admission denials. 
As of late October, HCFA had not responded to this concern. Pre-admission 
hospital 
denials are made by the  either on the basis of its own utilization 
review criteria or in anticipation of prior authorization review by the PRO. 
patient. 
Usually, there is not a formal written notice to the  PRO review 
under such 
circumstances could be quite difficult. It is anticipated that 
HCFA will issue clarifying instructions dealing with review of pre-admission
denials.  Informal Discussion, Not Formal Denial Notices, is the Usual Prelude to

Premature Di scharge 
Most of the time, discharge from the hospital follows an informal 
conversation between the patient and the physician during which the 
necessary. 
physician states that continued acute care is not  Patients or 
their families usually accept this decision and make arrangements for any 
notices are 
needed post-acute care. Formal denial  issued only when the 
hospital anticipates a problem because a patient might stay beyond the time

that acute care is necessary.

PROs a,n di to ther respondents feel that when premature hospi ta 1 di scharge does 
informal patient-
occur  is more likely to follow  physician discussion 
issued. 
rather than when a written notice has been  Before a notice can be 
issued both the  attending 
hospital utilization review committee and the 
physician have to agree that the patient is ready for discharge. If the 
attending physician does not agree, then the PRO has to review the case and 
concur or not concur with the hospital' s decision. The checks and balances 
protection to the patient that 
involved in these steps provide a degree of 
is not present in the more informal patient-physician dialogue that precedes 
patients
most discharges. PRO staff and some other respondents feel that 
usually leave the hospital when they are asked to, without protest and 
without appeal. The formal notice, on the other hand  spells out the 
right to  decision. 
patient'  reconsideration of the  In most cases, a 
patient'  denial. 
s protest will trigger the issuance of a written 
Moreover , improper and i nappropri ate reasons for di scharge are more 1 i ke 
to be conveyed as a part of informal discussion than through a formal 
notice. 
The physician may say, " Mrs. Jones, we are going to discharge you 
, II but 
tomorrow because Medi caret hwoen  t pay forr eycouor rcdar.e  any 1 anger  no such 
statement appears in  pat i ent  Occas i ona lly, PROs fi 
statemelln itns  to the effect that II patient was di scharged because DRG days were 
used Up medical records, but this is not common. When such statements 
are found they should trigger a review by the PRO. 
Because of these factors, some respondents feel that formal , wri tten not i ce 
should be given to all patients at least 24 hours before their discharge. 
Such notices would inform patients of the reason for discharge, discu 
set forth their 
arrangements for discharge planning and follow-up care, and 
appea 1 ri ghts and procedures. 
prior
Other respondents, however, point out that issuing such a notice just 
to discharge could " stir up" patients who properly should be discharged. 
days in 
Patients might try to use the appeals mechanism to buy time - extra 
the hospital-while their appeal is pending. Giving information on appeals 
alleviate
to patients-at the time of admission rather than discharge might 
this potential problem.  the responsibility 
HCFA has, in fact, restated 
process in an October 25, 1985 transmittal. Even so, respondents feel that 
more beneficiary education should be carried out.  ; "  , "

There is a Hi gh Level of Mi sconcepti on About PPS and Medi care Coverage; 
There is a Major Lack of Quality Educational Materials 
Beneficiaries and 
sophisticated providers alike indicate that there is a
high level of misinformation about Medicare coverage in general and 
PPS. 
specifically about  Efforts have been made by many orgtaoni zations,
including senior citizens and patient 
advocacy groups  provide 
done. 
PinRfOorsm aatnido no atbhoeurt  ihnofsopritmaalnitzsa tiinodni cunadteer  tPhPaSt,  tbhute  mborige gneeesdt sn etoe db ei s to hTavhee  
information on patients rights, benefits and responsibilities, including the 
appeals process, set out in a simplified format that could be given to all 
Medicare beneficiaries or their families upon admission or before admission
for an elective procedure. 
Material for general distribution is less 
effect i ve, since peop 1 e often do not read it unt i 1 there is urgent need. 
PPS. 
Physicians also have many misconceptions about  Physicians themselves,
as well as PRO staff and others, stated this. The most significant 
misconception is a lack of understanding that physicians are solely 
responsible for decisions concerning admission and discharge of patients, 
and should not abrogate that responsibility to the hospital or to any other
entity. 
As the medical director of one of the PROs put it  the PROs are 
the advocates for patients. Physicians need to know that if they feel they
are being pressured  they should let us know. Information about PPS 
responsibilities needs to go into the medical professional media.

number of senior citizen groups, such as congregate and home delivered 
meal sites, senior citizen centers and adult day treatment centers, are also 
anxious to provide educational programs on Medicare as a part of their 
serv ices. Many respondents commented that more shou 1 d be done to encourage 
cooper at i on and commun i cat i on between HCF A and programs funded by the 
Administration on Aging. 
Some efforts are being made by HCFA and other organizations to provide 
consumer information on PPS. 
The HCFA Office of Beneficiary Services issues on  monthly basis 
Medi care/Medicai d Notes.  These notes contai  factual information about 
the program thought to be useful to benefi ci aries. They are di stri buted to 
news media and various organizations for use in publications distributed to 
beneficiaries. The May 1985 issue, entitled "Medicare  s Prospective Payment 
System - What it Means and What it Does Not Mean II had the largest 
distribution of any of the "Notes.  In addition to regular channels, this 
issue was sent to the Administration on Aging for distribution to the Area 
Agency on Aging network. This issue tried to dispel such myths as "Medicare 
is orderi ng pati ents out otfh haots pital s  Medi care hospi tal reimbursement has 
been cut back"  and "  quality of care to Medicare patients
declining. 
The American Association of Retired People (AARP) has just issued (October
1985) a booklet on PPS called " 
Knowing Your Rights.  This material provides 
a basic description of PPS from the consumer s viewpoint. There is detailed  coverage on the role of the PRO and a section on the appeals process
entitled " How to protect your right to the care you need.  A list 
of the 50 PROs and thei r phone numbers is gi ven and benefi ci aries Bre tol d 
to contact PROs if they have received a denial notice and feel that they
have been den ied coverage prematurely or that they requi re further 
treatment.  its 
The AARP is planning to distribute this booklet to each of 
members and make it available to hospitals and other agencies on request. 
HCFA also publishes a pamphlet entitled "Your Right to Appeal Decisions on 
Hospital Insurance Claims.  This pamphlet deals with retrospective denials 
. on the grounds of coverage. It does not cover problems of pat i ents who are 
st ill in the hospi ta 1. The HCF A " Med i care Handbook" is st ill the standard 
explanation of benefits. Recent editions cover changes resulting from PPS. 
beneficiaries 
But revised handbooks go only to a small percent of Medicare 
(about 3. 5 mi 11 i on of the 35 mi 11 ion total). 
The California PRO has written to each member of the California 
Congressional and State legislative delegation urging their support to 
insure that Medicare beneficiaries and the general public understand that 
Medi care s efforts to curb unnecessary hospital i zat ions shou 1 d not result 
in a hospital' s failing to provide medically necessary care.  The PRO 
enclosed an article about PPS and quality of care concerns for the 
legislators to disseminate to their constituents. 
Tbehgeu AnA RtPo  bpouokblelit cizsee vtherea lr Cooleng orefss itohneal  PhReaOr iansgs  andp oostshiebrl es osuorucersc eh afover  
beneficiaries to take their appeals. 
staTfhfi.s  development has raised concern on 
tbheen epfaircti aorfie ss oames  PtRhOes  eanndt iHtCyF Aw hich woulAldt hroeusgohl vPeR Oas ncyou clod mbpe laviinetw eadb obuyt 
Medicare, they are obviously not staffed or  play such a role. 
funded 
For this reason, HCFA deliberately did very little until recently to educate 
PROs. 
beneficiaries or the general public on the role of  PROs were seen as 
This initial 
a contractor to HCFA to carry out specific review functions. 
view has been changing, however, and the PROs have recently been getting 
increased visibility. 
Respondents in this inspection supported publications such as those of . HCFA 
raensdp tohned eAnAtsR aPl. sTohe if er eful rtthheart  dgi essneemir analt d iiosnt riisb utot ioben  epnucobulircaagetido.n Hso dweov enrot 
substitute for information given to the patient " on the spot " either at 
admission or at the time of discharge from a hospital. 
In the past  hospitals had an incentive to help patients appeal denial
notices. 
Under PPS, the burden of submitting appeals has shifted to 
families. 
patients and their  This change makes it far more important that
clear 
, detailed information on appeals be readily available. 
Consumer Representatives Have the Potential for More Active Roles on Boards

of Peer Review Organizations

Several PROs have added consumer representative to their boards in the past
 several months.  these  active in the 
Most of  consumers are  American 
affiliates. 
Athsseoc ciaotnisounm eorf  rReeptrierseedn tPaetrisvoenss  aorr eo nceo olfle icttsin sgt aintefo rmation andC ourrireennttilnyg, 
themselves to PRO functions and activities. Active programs of assistance
and  beneficiaries are being 
education for  planned but have not yet been
implemented. Board members are surveying beneficiaries and looking into 
submitted. 
wspeiclli ffiocr mcoumlpaltaei nptrso gtrhaamts  hfaovre  bdeeevne loping benefiBcaisaerdy  one dtuhcisa trioense aarncdh a,p ptheeayl 
rights, participating in PRO review of quality of care, and providing more 
explicit assistance to beneficiaries following their hospital discharge. 
Consumer participation in PRO activities is currently limited both in 
numbers of PROs participating and in scope of activities. PRO directors, 
however , feel that consumer board members offer high potential for helping 
to alleviate quality of care problems. 
HCFA has been informally working with AARP to develop a national training
program for PRO board members. This training program would stress the role 
of board members in helping to insure quality of care. 
There is no HCF A or Congress i ona 1 mandate for PROs to have consumer members 
boards. 
on their  Some PROs will not allow such representation or any kind
of " outside 
" training such as that proposed by AARP. 
Many Beneficiary Complaints Concern Inadequate Discharge Planning and

Fa II ow-up Care 
Many beneficiary complaints sent to HCFA  Congress, the PROs and other 
sources actually concern inadequate di scharge p 1 ann i ng and sub-acute care 
fo 11 owi ng di scharge. When inadequate arrangements are made for post 
in the hospital. 
hospital care, some patients will end up back  In one case 
referred to HCFA from the mid-West, a patient was readmitted to the hospital
four 
times within 6 weeks because of poor discharge pl anning by that
hospital.  to 
The hospital failed  describe the difficult and combative 
nature of the patient because it knew nursing homes would not accept such a
patient. 
Absent this description, nursing homes accepted him for a short 
hospital. 
time, then returned him to the  In commenting on this case the 
HCFA regional office said that lIextended ambulance rides and subsequent 
the  direct result of 
return to  hospital for readmission were the  poor 
discharge planning on the part of the hospital -- an accredited facility,
the 
hospital is responsible for discharge planning. In this case, calls 
were made to the nurs i ng home to reserve beds; however, the pat i ent' s 
behavior and condition were not adequately explained.  The PRO followed up
the case by tak i ng correct i ve act i on with the hospital. Poor di scharge 
planning is felt by many respondents to lead to subsequent readmission or 
patients. 
even to the death of  Discharge planning is a critical factor 
affecting the well-being of patients and their overall quality of care.

This particular 
case, and others like it, come to the attention of HCFA and 
the PRO because the beneficiary s family documented the problems in writing 
and enlisted the assistance of a local patients ' advocate organization.  The relationship of PPS to discharge planning is now getting attention 
profession. 
within the  The Society for Hospital Social Work directors of 
the American Hospital Association is holding a series of conferences around 
the country on the theme "How Discharge Planning Works - and Can Work for 
You - Under Prospective Payment.  As a part of their statement on discharge 
planning, this group stated " Social workers must view with alarm the 
currently ri si ng pressures for hurried, depersonal i zed transfer of pati ents 
cost-effectiveness. 
out of acute care hospitals as a part of the thrust for 
Existing criteria for determining levels of care by bodily needs alone are 
inadequate and often misleading.

PRO Review is Not Adequately Targeted on Patient Discharge or Discharge

Pl anni ng 
fQuoalr  iatdym ofis sciaorne si, sD RsuGp pvoasleiddlayt ireovni eowre da nbyy  PoRtOhs ewrh epnuevrepro tshee.y  Mreovsite wc arseceosr dosf 
premature discharge, however, come to PRO attention only upon review of 
patients who are readmitted to the same hospital within seven days from the
first 
discharge. A patient who is readmitted after seven days, or is not 
readmitted at all, may still suffer because of premature discharge or lack 
of adequate discharge planning. Unless a complaint is filed by a patient or
a patient' s representative, however, this lapse of care will probably go 
unnot iced. 
Some PRO staff, physicians and others feel that additional reviews should be 
carried out by the PROs in order to plug this gap in quality of care review. 
There are several variations of review that potentially could be performed
but are not now. These include (A) targeted patient discharge review; 
(B) concurrent patient discharge review; (C) day-of-discharge review; and

(D) review of discharge planning. A more explicit focus on review of 
discharge and discharge planning would greatly reduce the incidence of 
premature di scharges and inadequate di scharge pl anning. 
Such reviews should not be viewed as adding additional onerous requirements 
on the PROs or on hospitals. Many hospitals will be putting more resources 
so. 
iinst o discharge planning because it is in their self interest to do  This
as 
especially so 
they move towards horizontal expansion  taking on 
services such as nursing homes, hospice and home health agencies. 
An inquiry was made to the Joint Commission on Accreditation of Hospitals to 
obtain results of survey findings concerning hospital discharge planning. 
below. 
The results of this are shown in the chart  This shows that at least 
four of the survey elements pertaining to discharge planning have negative 
findings in ten percent or more of the cases: 
10
 " %
1983  1984 
Total Numbers Survey Reports Analyzed  1797  1472 
Record Serv ices 
Medi ca 1 
Does the clinical resume contain at least the condition  140* 
of the pat i ent on di scharge? 
357* 
Does the clinical resume contain at least pertinent
instructions for further care (e.g. 
, physical activity 
limitations, medications, diet)?

Do nursing department/service entries in the patient' 
medical record include a final nursing progress note 
reflecting the patient' s status for transfer within 
the hospi tal and/or di scharge from the hospi ta 1 ? 
40 
Do nursing department/service entries in the patient' 
medical record include an indication of the patient' 
or family s understanding of instructions given to 
patients who are discharged from the hospital on 
regiment? 
nurs i ng care 
Social Work Services

Do the social work services policies and procedures
 66 4

relate to consultation and referral procedures?

Do the social work services policies and procedures

relate to the role of the social work department/

serv i ce in di scharge p 1 ann i ng. 
Nursing Services 
Does the written nursing care plan include consi
 247 14  221 
deration of patient education and patient/family

knowledge of self-care?

Does the written nursing care plan include nursing
 429 24  469 
measures that will facilitate the medical care pre
scribed and that will restore, maintain, or promote
the patient' s well-being? 
11
 ll %  ll %

Ut i 1 i zat i on Rev i ew 
Does the utilization review plan include a mechanism

for provision of discharge planning?

Source:  JCAH Aggregate Survey Data (ASD) 
* Data not accumulated into JCAH system until April 1984. 
Physician Decisions Are Not Usually Challenged 
10. 
Sen i or advocacy groups, some PtRhO est aff and others stthreesisre d the reluctance of 
beneficiaries to challenge  decisions of  otheprhsy.s icians or the 
information given to them by hospital staff or  In many cases 
beneficiaries cannot read or understand the information given to them , yet 
are very reluctant to admi t thi s or to ask questions. As one provi der at a 
neighborhood clinic put it "Elderly patients are reluctant to make demands 
on the system. It is a matter of pride with them. They do not realize that 
they are entitled to good health care and that Medicare is not welfare. 
Another respondent, a senior activist herself, stated lI older patients do not 
understand the process, are intimidated by the physiciraingsh atnsd.  everyone else 
in the system and simply won t speak up about their  Someone needs 
to speak for them!" 
Nearly all of the senior advocate group representatives and many of the PRO 
staff agreed with these sentiments. At a time when patient assertiveness 
essential  the facts are that patients will seldom challenge those in 
authority. 
12
 CONCLUSIONS 
Written denial notices allow hospitals to terminate acute care benefits to 
discharged patients 
Medicare beneficiaries. However, only a small number of 
notices. 
actually receive written  Current HCFA procedures for issuing notices 
and for their review by the PROs appear to provide adequate safeguards to
patients.  been largely 
Problems which did exist in the content of notices have 
eliminated with the issuance of new HCFA procedures in May 1985. 
This study indicates that cases of premature hospital discharge usually do not 
issued. 
occur when a formal den i a 1 notice has been  When a case of premature 
discharge is identified , it more likely follows an informal discussion between 
families. 
the physician and his patients or their  During this discussion, the 
physician is likely to give as a reason for the discharge that DRG days have 
longer. 
been used up or that Medicare will not pay any  Notations to this effect 
oPcRcaOsiso.n ally appear in medical records, rneosu rlteicnog ridn  ocofr rveecrtbivael  action by the
More often, however  there is  commun i cat ion s 
discharge. A written  not issued 
concerning patient  notice is  unless the 
hospital initiates the discharge, or the patient complains. 
Unless the patient is readmitted within seven days, cases of premature discharge 
identify. 
in the absense of a written notice or other record are difficult to 
groups have urged that
For this reason, some of the PROs and patient advocate 
written notification be issued for all discharged patients, that the notice 
spe 11 out an appeals procedure and that it be subject, under some ci rcumstances, 
. review by the PRO. An expanded review role by the PRO covering discharges 
and discharge planning has also been advocated. 
respondents 
Lack of knowledge about PPS provisions is widespread. Vairst ubaelnlye failcli aries. 
urge education campaign covering providers as well  This 
campaign would encompass many facets, including articles in the professional 
i on of constituents,  i nformat i on not 
medi a, Congress i ana 1 educat  and benefi ci ary 
hospitals, but  gather or 
only in  in any other location where senior citizens 
receive services. Coupled with increased vigilance on quality of care review by
the  resolve 
PROs, educational campaigns would help  premature discharge and 
qua 1 i ty of care prob 1 ems. 
Social Security also plays a role in providing information about Medicare as 
well as in determining eligibility. The SSA District Offices are the focal 
point for beneficiaries to get an explanation of their Medicare benefits and to 
get answers to questions they may have, including questions on denial notices. 
attention. 
HCFA staff feel that SSA is not giving these responsibilities enough 
For example, they have not been made a performance element for evaluating the 
management of a district office. There is need to update and give higher
priority to a memorandum of understanding between HCFA and SSA concerning
beneficiary services activities. 

gi ve the appearance of 
In the past HCFA has been very careful not to intrude or 
intruding in the physician-patient relationship. This has certainly been 
appropriate. But a balance must be struck. Not intruding can also give the 
in quality of care. 
appearance of not caring, of condoning lapses  HCFA and HHS 
appear now to be leaning too far on the side of not providing enough information

to beneficiaries.

13 RECOMMENDATIONS 
The OIG recommends that HCFA

INITIATE REQUIREMENTS to insure that hospitals provide patients , at the time
of their admission, with complete information on Medicare requirements for 
discharge. 
hospital admission and  This material should cover such areas as 
hospital admittance procedures, covered and non-covered services , discharge
decisions  and patient appeal rights. While many hospitals currently 
furnish such information, there is no uniform set of requirements to date. 
HCFA should determine how best to implement -this new requirement and report 
results to the OIG no later than March 31, 1986. 
HCF A Comments 
(A) requiring that 
HCFA agreed with this recommendation and has initiated action 
hospitals furnish patient such a statement of appeal rights upon admission to 
that this 
the hospital and (B) to require that PROs monitor hospitals to assure 
is done. 
DEVELOP MATERIALS that would clearly and explicitly inform physicians of 
their responsibilities under PPS, including the fact that they have the sole 
patients. 
responsibility for decisions about the admission and discharge of 
fiscal 
Instruct carriers and  intermediaries to issue special reminders of 
PPS physician responsibility, and request PROs to emphasize it in newsletters 
distributed to the provider community. Provide similar material to members 
of hospital boards of trustees. 
HCF A Comments 
not 
HCFA did  respond to this recommendation  and the OIG would urge that
additional steps be  providers of their 
taken to inform physicians and other 
responsibilities under PPS. 
COLLABORATE WITH APPROPRIATE OHDS STAFF OFFICES and wi th the Admi ni strat ion 
on Agi ng to develop materi a 1 s  and strategi es for increased educat i on and 
beneficfaries. 
information about hospital stays for Medicare  This should 
include: 
Steps to develop and issue precise, cloeafr  , and readable educational
literature informing beneficiaries  their coverage, rights, 
PPS. 
pdreivveilloedpgeeds  iannd  croelslpaobnsoirbaitlioitni ews iutnhd egr roups, Ssuuchc hma atesri tahlse s hAomulerdi cbane  
Association of Retired Persons, and build on materials that already 
exist. A high priority should be given to educational packets provided 
hospital or prior 
to patients and their families upon admission to the 
to admi ss i on. 
Greater utilization through OHDS of the "Aging Network" as a means to 
reach Medicare beneficiaries and get information to them. 
14 Increased use of volunteers who could serve as advocates for Medicare 
patients  hospitalization. 
before, during, and after  OHDS should take
the 
lead in disseminating information about model volunteer programs 
already established by some area agencies on aging. 
HCF A Comments 
HCFA responded by describing a number of collaborative actions which are being
initiated or are 
underway to improve the education of beneficiaries about 
hospital stays under PPS. 
WORK WITH SSA to insure that appropriate informational materials are 
daviasitlraibclte  ofofrf idciestsr.i bution to Medicbaere  beneficiaries through Social Security
staff  Steps should  ttaoke n to insure that Social Security
have sufficient training  discuss Medicare issues 
with 
beneficiaries. A memorandum of understanding should be developed between

HCF A and SSA to insure that these goals are met.

HCF A Comments 
HCFA agreed , and described steps being taken to strengthen communication with 
beneficiaries at the district office (DO) level. HCFA agreed that a HCFA/SSA 
Memorandum of Understanding would be helpful to promote a dileneation to 
responsibilities for beneficiary education. 
SSA Comments

the  to 
SSA agrees with  recommendation that  HCFA work with SSA  insure that 
information is available for distribution.  SSA listed a number of actions taken 
over the past two years to achieve this.  SSA di sagrees that a foma 1 HCF A/SSA 
Memor andum of U nders t an din g is needed. 
INSURE THAT ADEQUATE FOCUS is given to review of patient discharges by the

PROs for the 1986-1988 contract peri ad. The draft speci fi cat ions prepared 
bcyo nHCtrFaA cdtos  psrhoovuidlde  ifnorc liundcere sasoemde  atotre natiloln  otof d tihsceha rfogell orweviinegw. e Tlehem feinntasl  
appropri ate:

all 
Quality Screens  Apply generic quality screens to  cords 
reviewed , as stated in attachment 3 of draft PRO Scope-of-Work. 
Targeted Patient Discharge Review - Identify a sample of patients to be 
targeted for retrospective review of discharge similar to the five 
percent sample of patients identified for admission review. The sample 
cou 1 d be random or se 1 ected from among hi gh-ri sk pat i ents where 
premature di scharge is more 1 i ke ly to occur. 
Concurrent Patient Discharge Review - Undertake a review of a sample of
hospitalized patients slated for discharge.  Review notification of 
discharge, as above, or target a select group of patients at risk of
premature di scharge. 
15
 tDoay -of-Discharge Review  - Review the services and procedures rendered
conajunn catpioprno wpriitahte  ussamep loef o fq uaplaittiye nstcsr eoenn st he tdoay  doeft edrimscinhaer wgehether 
i nappropri ate acute servi ces were provi ded. 
Discharge Planning Review - Require a more explicit focus on review 

planning  done by the hospital to insure that it is adequate. 
discharge 
HCF A Comments 
HCFA described a number of steps taken to focus PRO reviews of hospitals which 
address the OIG recoommendations. HCFA, however  suggested deletion of 
recommendation 5e that a finding of inadequate discharge planninigs w ould call
into question the conditions of participation  since this  the PROs
responsibility. The OIG agrees with this suggestion, and is deleting that 
port i on of the recommendat i on. 
CONSIDER SELECTIVE REVIEW BASED ON DEATH CERTIFICATES. Several PROs have 
looked into performing a review, on a selective basis, of death certificates 
issued to recently discharged patients. By examining patient records for
these 
cases the PRO woul d determi ne whether premature di scharge or poor 
the death. 
quality of care may have contributed to  The feasibility of 
requiring such a PRO review activity should be evaluated. 
HCF A Comments 
HCFA agrees with this suggestion and considering instituting a study to expand

PRO review of deaths that occur shortly after discharge.

16