Home Health & Hospice Week

Follow tips from the experts on documenting a refusal to sign the notice of termination.

If you're confused about your responsibilities under the new fast-track appeals process for Medicare managed care patients, you aren't alone. But there are a few things experts can agree on.

Unfortunately, the Centers for Medicare & Medicaid Services has left many gray areas in the Grijalva appeals process, health plans and providers lament. One particularly confusing issue is what to do when a Medicare Advantage enrollee refuses to sign the initial Notice of Medicare Non-Coverage (NOMNC). Can the nurse document the refusal, or is an additional witness needed?

Nurse documentation should be enough to do the job, industry experts agree. Instructions from Michigan Quality Improvement Organization MPRO indicate that "if the patient refuses to sign the notice, the home health agency will annotate its copy of the notice to indicate the refusal," reports Michigan-based consultant Linda Rutman with the LarsonAllen Health Care Group. The date of the refusal is considered the notice's date of receipt, the MPRO instructions say.

An authorized representative, as required by state or federal law, must sign for an incapacitated patient deemed incompetent to sign for reasons such as senile dementia, the MPRO instructions add.

"CMS hasn't addressed this issue specifically on its Web site," rues Mary St. Pierre with the National Association for Home Care and Hospice. But St. Pierre believes "documentation of the patient's refusal is sufficient, just as it is in other cases where patients refuse to sign documents."

"A nurse can go ahead and simply document the patient's refusal like she would document anything else; a witness is not necessary," agrees attorney Virginia Caudill with Indianapolis-based Gilliland & Caudill.

Heather Vasek of the Texas Association for Home Care compares it to procedures for advance beneficiary notices. "For regular HHABNs the nurse can just document in the record the patient's refusal," Vasek notes.

HHAs generally should follow ABN guidelines on signature requirements for the new notices, CMS said in a Jan. 22 Open Door Forum on the appeals (see Eli's HCW, Vol. XIII, No. 6).