Getting ready for MOON

Learning objective

At the completion of this educational activity, the learner will be able to:

• Identify challenges related to implementing the Medicare Outpatient Observation Notice (MOON) and the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act.

When CMS decided to postpone the MOON notification requirement a few days before the scheduled implementation date of August 6, it provided a welcome reprieve for many hospital staff members who were scrambling to get ready (see related story on p. 1).

"We were almost ready to go, however, plans are actually now on hold until the final draft is approved, in probably January," says Frantzie Firmin, MS, RN, director, utilization management and care coordination of Brigham & Women’s Hospital in Boston.

The hospital’s preparations included development of a process to deliver the notification to patients who needed it.

"Our organization, Partners Healthcare System, has decided to address the MOON implementation systemwide. As a result, we set up a case management expert panel, which is a collaborative practice committee that meets regularly to address and develop a plan that will ensure regulatory compliance across the system," she says.

The group worked with the electronic medical system team to develop an automated workflow directly within the system. "Each hospital has its own work queue set up," says Firmin. "The Medicare patients in the work queue are only those in observation status that have been there 12 hours or more."

Care coordinators and insurance support nurses have access to the work queue, which allows them to identify their observation patients. "Furthermore, we have also added functionality in [our electronic system] to document that the notice has been given," she says. Staff members are able to check off the status and date of receipt for each patient, and then the patient’s name moves out of the work queue.

The system also allows the insurance support nurse or care coordinator to print the form and provide a copy to the patient before discharge.

Other organizations had taken similar steps.

RWJ Barnabas Health in Toms River, New Jersey, also formed a small task force to ensure compliance with MOON, says Shawna Grossman Kates, MSW, MBA, LSW, CMA, the organization’s case and bed management director. But while MOON is new to them, this type of observation notification requirement is not. New Jersey hospitals have already been subject to an even more restrictive patient notification requirement for several years, she says.

Hospitals in New Jersey must issue a letter to patients detailing their status at the time of placement.

Sometimes that’s difficult to do. It requires different portals because notifications may affect everyone, from the elderly adult coming in through the ER to pediatrics observation patients or labor and delivery observation patients.

"To some degree, the emphasis on MOON has instigated a renewed attention to make sure we’re in compliance with the state of New Jersey’s regulations and that we have continuity and standard practices on a systemwide basis," she says.

Massachusetts General Hospital in Boston has come up with a workflow for how the form will be delivered and a communication plan to deliver it, says Nancy Sullivan, MBA, CMAC, executive director of case management at the organization.

But like other organizations, plans at Massachusetts General Hospital are on hold as CMS prepares the final version of the new MOON form.

Part of the hospital’s initial plan to comply with MOON prior to the postponement was to print a daily report that listed the patients who would need the notice and to use case management resource specialist staff members, who provide support to case managers, to deliver the notification. The hospital worked with staff members to develop a training script.

A challenging requirement

While case management experts agree that notifying patients and giving them information about their status is the right thing to do, there are significant challenges they are trying to work past to make the notification a reality.

For example, CMS’ new proposed form, says Kates, is not written in simple language that is easy for most patients to understand. "The Medicare MOON document is not third-grade reading level language," she says. This means that unless CMS makes changes to the form before finalizing it, there will be an additional burden on staff members delivering the notification to clearly explain it to patients. Many organizations will likely need to come up with simpler materials to augment the form to help patients understand the complex subject matter.

Organizations are not permitted to modify the finalized version of the MOON form. "But many are coming up with a one-page handout or an FAQ, or adapting their state hospital association FAQ on observation documents," says Kates.

While CMS estimates the notification process would take about 15 minutes per patient, says Sullivan, it’s likely to take much more staff time due to the complexity of the material.

"The kinds of topics that they plan to include in the letter are complicated," she says.

The challenging nature of these discussions was reinforced by a recent conversation Sullivan had with an elderly family member whose husband was admitted to the hospital.

The woman had called Sullivan in hopes of having her explain all the hospital jargon and insurance-speak. Trying to explain the billing nuances involved in skilled nursing facilities and Medicare Advantage is no easy task, says Sullivan?particularly if the family is in the midst of a medical crisis.

"I feel like the patient should know what their financial responsibilities will be, I support the concept," she says. But at the same time she says she also understands the real challenges hospital staff members involved in delivering that information will face.

Another factor complicating the notification is that it’s unclear how many languages the document will be available in. At Massachusetts General Hospital, patients speak a multitude of languages so the hospital will likely need translation services when delivering the written and verbal notices.

A third challenge is having a system in place to ensure all the patients who need notifications, get them.

"The biggest implementation challenge will be to ensure we have a mechanism in place to capture all the patients that have been in observation across the hospital," says Firmin. "Although we have a dedicated observation unit, we often have observation patients overflowing across the hospital."

In order for the notification process to be successful, staff members?including nursing staff?should be engaged in the process, says Sullivan. Ideally, nursing staff should have a working knowledge of these issues, particularly in the event a case manager isn’t available and a patient starts asking questions.

It remains to be seen what the final MOON form will look like. CMS opened a 30-day comment period on the MOON August 1 and has said that the rule will go into effect no more than 90 days from the finalization of the form.

Based on this timeline, Kates says she anticipates a January 1 start date, but that remains to be seen.

In the meantime, organizations will be waiting to see the final result of this process, and from there determining how to comply.

HCPro.com – Case Management Monthly