The OIG, ABN, IMM, and DND in the News

Let’s start with a recent (U.S. Department of Health and Human Services Office of Inspector General) OIG audit of a Medicare Advantage plan. Now these are certainly not unique. Every time the OIG audits an Medicare Advantage (MA) plan, they find diagnoses submitted as HCCs that are not substantiated by the medical record.

And in this audit, it is the usual suspects, diagnoses that the patient had at one point in the past but that are not active, like cancer, heart attack and stroke. And as usual, the MA plan objected to the OIG’s use of extrapolation and lack of review for diagnoses that were missed that could have increased their payment.

And as usual, the OIG brushed them off.

But what really stood out was one denial of a lung cancer HCC that the MA plan could not defend because the medical records could not be obtained. The reason? The provider was incarcerated and the medical records had been seized by law enforcement. It is hard for me to side with an MA plan but I am going to give them this one, as did the OIG by removing the case from their audit.

Next, as I noted last week, CMS released the new ABN and then last Tuesday they released the new Important Message from Medicare and the Detailed Notice of Discharge. And since you count on me to be highly critical, I’ll point out that the ABN changed from check boxes to circles for the patient to choose an option. But they did not adjust the instructions so they still indicate that the patient or representative must check one of the boxes. Apparently plain language guidelines for forms no longer allows boxes. And they told me that they will consider modifying the instructions in three years when the form next needs approval. So, for three years we must ask patients to check a box when there are no boxes to check.

The Important Message from Medicare has some format changes and a new font. What is most interesting to me is that they added a bullet that says, “After you leave the hospital, you can still appeal.” How does one appeal their discharge from the hospital if they have already been discharged? If they do that and win, does the hospital have to admit them back to the hospital and reopen the previous encounter?

Does the patient have to be forced to come back? It’s bizarre.

It also states that the QIO will render an opinion on a discharge appeal in two days, whereas the old IMM said one day. Isn’t that great- another day for a patient who does not need hospital care to remain and prevent a patient in the hallway in the ED from getting the appropriate care they need.

And finally, the Detailed Notice of Discharge. While the content has not changed, there format certainly has. The old DND was one page. But the new DND, as initially posted on the CMS site, is three pages, with the third page being completely blank. And the manuals clearly state that “Unapproved modifications cannot be made to the OMB-approved, standardized DND.” So does the patient need to get that third blank page?

I did notify CMS as of the date of this writing, they changed the Word version to two pages but not the PDF version. And that begs the question: which version is the official version that must be followed? I hope by the time this is published that CMS has sorted it out. You can find out by downloading the  Detailed Notice of Discharge zip file at the bottom of the IMM/DND page.

In addition, the second page simply has a paragraph, in nine-point font no less, about the form meeting the requirements of the Paperwork Reduction Act, which of course is the ultimate irony in that inclusion of the paragraph required adding a second page, increasing the paperwork to accommodate a statement about reducing paperwork.

And now that the mandated documents are all updated, the wait for the 2027 IPPS Proposed Rule starts. But I suspect that something notable will happen in the interim for discussion so keep reading RACmonitor every week.