Question on the HINN

Q.  We are not sure how to implement the Preadmission/admission HINN. At what point [does] it get delivered to the patient? Does there need to be an inpatient order? If they did not meet inpatient criteria, why would there even be an inpatient order? I could see this possibly happening for direct admits from the doctor’s office in which the hospital is not in agreement. But what about those in the ED where the majority would be? Our understanding is this is used for patients who do not meet either Observation or Inpatient criteria.

A. In order to be effective, a Preadmission/Admission HINN must be delivered to the patient (or his/her representative) no later than the date of admission.  Ideally, the HINN would be delivered at the earliest opportunity, if not prior to admission, then at the time of admission, during the registration process.  The inpatient stay generally begins at the time of the physician’s written  admission order, so whether there’s a written order at the time of delivery of the HINN depends upon when the HINN is provided.  If provided prior to admission, there would be no written order.  If provided after admission, presumably there would be a written order.

Remember, that it’s the physician who orders the admission.  Although in the best case scenario the physician’s decision as to whether to admit to inpatient care or to order outpatient observation is guided and informed by case management (CM) and utilization review (UR) staff, it ultimately is the physician’s decision.

In the case where the hospital believes that the admission does not meet inpatient guidelines for coverage under Part A, the hospital must provide the Preadmission/Admission HINN in order to reserve its right to bill the patient if Medicare denies coverage for that stay.  When a HINN is provided, the hospital is simply stating that, based upon its understanding of Medicare inpatient guidelines, the hospital doesn’t believe that Medicare will pay for the stay under Part A.  Medicare, however, will ultimately determine whether that stay is covered under Part A.

The Preadmission/Admission HINN is most likely to be used where the patient understands from the outset that this stay is not likely to be covered by Medicare, and they are expected to assume responsibility for that inpatient stay.  Perhaps they have other health care coverage that they believe will cover that inpatient stay.

The Preadmission/Admission HINN only indicates that the hospital believes the inpatient admission does not meet Medicare’s inpatient guidelines.  Observation services are outpatient services.  Therefore, different coverage criteria apply to determine whether observation services will be covered by Medicare.

If covered, those observations services will be covered under Part B, not Part A.  In those cases where it isn’t clear that the patient currently meets inpatient guidelines, but the physician determines it isn’t safe to discharge the patient, it may be appropriate for the physician to order observation care to monitor the patient and obtain additional information regarding further care.  It would be inappropriate to provide a Preadmission/Admission HINN when the hospital believes that the observation care meets Medicare medical necessity requirements.

Editor’s note: This question was answered by Judith L. Kares, JD, an instructor for HCPro’s Medicare Boot Camp – Hospital Version. Kares was a speaker on the HCPro, Inc. audio conference, Master the HINNs: Integrate Policies and Procedures into Hospital Operations.