Surveying the MOON
Edward Hu, MD CHCQM-PHYADV , Member of the ACPA Board of Directors
A New MOON
CMS made two important releases in the first week in August that will help hospitals manage the intricacies of the Medicare Outpatient Observation Notice (MOON). We refer the reader to the draft version of the MOON.
First, you will notice that this draft has not been assigned an official OMB number yet. It also contains several differences to the previously proposed MOON released in April. The most obvious change is that there is now a large free text area stating "You are not an inpatient because:" where hospitals are instructed to give the "specific reason" the patient is in outpatient observation. This section will cause hospitals the most consternation, because explaining the "why" will be very difficult without delving into Medicare regulations (which admitting providers often do not understand). Any detailed explanation will likely give rise to more questions than answers. CMS does note that they will consider “checkboxes with common reasons” in the future which suggests that hospitals could develop their own check boxes to use as an explanation.
CMS felt that the NOTICE Act required them to leave in reference to a beneficiary's Part B cost sharing requirements for physician services, even though copayments for doctor services are essentially the same whether an inpatient or outpatient. In the final rule Preamble, CMS acknowledged that in many instances the "observation bundle" (APC 8011) will only trigger a single copayment rather than "a copayment for each hospital service you get," but elected not to include this explanation on the MOON.
The next section attempts to explain eligibility for SNF care after a hospital stay. The statements here will be accurate for most patients, although CMS recognizes that certain alternate payment models have a 3 day SNF waiver that does not require the same qualifying inpatient stay. CMS is choosing to not mention that in this section, leaving it up to the hospital to explain that in the additional information section on the back if applicable. The "NOTE" section contains a huge omission, one that ACPA asked CMS to include but they did not.
"NOTE: Medicare Part A generally doesn't cover outpatient hospital services, like an observation stay. However, Part A will generally cover medically necessary inpatient services if the hospital admits you as an inpatient based on a doctor's order..."
The omission is that this section omits any reference to the rules that govern an inpatient decision. ACPA suggested that a statement be included that the status decision is made based on Medicare policies without regard to beneficiary cost-sharing or SNF eligibility. Our statement was specifically referenced in the published comments but not responded to. Hospitals should be ready to explain that "your doctor cannot just write an inpatient order so Part A will cover your stay."
CMS removed the reference to calling the Quality Improvement
Organization if the patient has a concern about the quality of their care,
based on numerous comments (including ACPA's) that beneficiaries may
erroneously believe that the MOON and the outpatient observation decision are
appealable. They are not appealable. Instead, there is only a generic reference
to the 1-800-MEDICARE number.
Page 2 of the form starts with an explanation of
non-coverage of self administered drugs (SADs) by Part B. CMS addressed
commentary by ACPA and others that the OIG will not penalize a hospital that
routinely discounts or waives SADs as long as OIG requirements are met. If a
hospital does waive or discount SADs, CMS will allow the hospital to state that
in the "Additional Information" section. One of the OIG requirements
is that the discount is not marketed or advertised. CMS' guidance should help
allay any concerns that stating your SAD policy in the MOON "Additional
Information" section would be construed as marketing or advertising...
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