Driving Reliable IM Compliance Through Standardized Processes
By Marie Stinebuck, MBA, MSN, ACM
The delivery of the Important Message from Medicare (IM) is a longstanding regulatory requirement intended to inform Medicare beneficiaries of their inpatient status and their right to appeal a hospital discharge. While most case management and utilization review teams understand the basic timing requirements for delivery, confusion often arises around the operational details that follow issuance of the second IM, particularly when a patient elects to request an expedited discharge appeal through the Quality Improvement Organization (QIO).
IM delivery is a process ingrained into every case management program. In this article, we will address some of the most common areas of confusion related to IM delivery requirements and the process for delivering the IM letter. IM delivery does not require a professional license. This is a logistical task that should be performed by support roles such as the case management assistant. The RN and social worker roles should be reserved for assessing and developing the plan of care for the most complex patients requiring case management services.
National benchmarking indicates that hospitals achieve an average 80–85% delivery compliance rate for the second IM, which is generally considered an acceptable threshold for demonstrating a reliable and sustainable process for notifying Medicare beneficiaries of their discharge appeal rights. While organizations should always strive for continuous improvement, maintaining compliance within this national range reflects a standardized workflow that accounts for real-time discharge variability and patient availability.
If your organization is still struggling with a low compliance rate, consider creating achievable goals for your team and celebrating incremental improvements. For example, a 10% improvement over a six-month period with outlined process enhancements will steadily increase your compliance percentage. Accrediting organizations are looking for a consistent, compliant process that demonstrates continued improvement, not perfection.
Confusion still exists regarding whether the second IM requires a patient signature at the time of delivery. If the follow-up paper notice is a copy of the originally signed IM provided at admission, an additional signature is not required. However, if a blank or unsigned IM is issued as the follow-up copy, a signature must be obtained from the patient or their authorized representative. CMS encourages hospitals to document delivery through initials or staff verification within the patient record to demonstrate compliance with notification requirements. Delivery also requires documentation in the patient’s medical record.
Questions also arise regarding the timing of delivery on the day of discharge. CMS outlines in Section 200.3.4.2 of the Medicare Claims Processing Manual the requirement for delivery of the second IMM within two days of discharge. Guidelines allow delivery of the letter no sooner than two days before discharge and allow delivery of the follow-up IM on the day of discharge. However, this practice cannot occur routinely. When the IM is delivered on the day of discharge, the hospital must allow the patient to remain inpatient for at least four hours following delivery to provide adequate time to consider or initiate a QIO appeal request. Patients who agree with the discharge plan are not required to remain hospitalized during this period.
Hospitals are also prohibited from pre-scheduling delivery of follow-up IMs on certain days of the week, such as issuing all notices on Mondays, Wednesdays, and Fridays. This practice violates CMS Section 200.3.4.2 instructions requiring delivery no more than two calendar days prior to the anticipated date of discharge and may conflict with Conditions of Participation related to patient rights. If a patient receives a follow-up IM but remains hospitalized two days after delivery, an additional follow-up IM must be issued prior to the next proposed discharge date.
The IM letter outlines the patient’s ability to appeal their discharge if they feel they are being discharged too early or do not feel they have a safe discharge plan in place. A Medicare beneficiary must submit a timely request for QIO review of their discharge. When this occurs, the patient cannot be held financially responsible for any portion of their inpatient stay while the QIO is conducting its review. Financial liability may only shift to the patient after the QIO issues its determination regarding the appropriateness of discharge. The patient must be made aware that their discharge has been upheld and that they will be held financially responsible for their continued stay the following day beginning at noon. If the patient elects to remain in the hospital after the QIO denial, the hospital must notify the patient that Medicare coverage has ended and inform them of their potential financial responsibility, typically through issuance of a Hospital-Issued Notice of Noncoverage (HINN 12).
Patients do have the option to pursue a second appeal related to their discharge. Medicare coverage does not automatically continue during the second-level appeal, known as reconsideration through the Qualified Independent Contractor (QIC). Once the QIO upholds the hospital’s discharge decision in the first-level appeal, Medicare coverage for the inpatient stay ends as of the effective date determined by the QIO. The patient becomes financially responsible for the stay, as discussed above, beginning at noon the following day after their discharge appeal has been denied. Although the patient may choose to remain hospitalized while pursuing a second-level appeal, the hospital may begin holding the patient financially liable for inpatient services received after that effective date. This represents a key distinction from the first-level QIO appeal, during which Medicare continues to cover the inpatient stay and the patient cannot be held financially responsible while the review is in progress.
Understanding the regulatory requirements surrounding IM delivery is essential to ensure both patient rights and organizational compliance are maintained. While the process itself is operational in nature, failure to adhere to timing, documentation, and appeal notification requirements can result in compliance risk and financial liability for the organization. Establishing standardized workflows, delegating delivery responsibilities to appropriate support roles, and maintaining consistent documentation practices will support sustainable compliance with CMS requirements while allowing licensed case management professionals to focus on complex discharge planning and care coordination activities.
Reference: Medicare Claims Processing Manual