Medicare beneficiaries and their advocates who question the appropriateness of a proposed discharge from a Medicare hospital, whether the discharge is too soon or whether necessary post-hospital services have been arranged, should contact the local Quality Improvement Organization (QIO) and file a complaint.
Full Answer
What does safe discharge mean for Medicare?
Safe discharge is the key term Medicare uses, and you can use it, too. In your appeal, state that you don’t believe the current plan meets the needs of safe discharge as defined by Medicare. Even if you are not a Medicare patient, using the terminology may sway the decision in your favor.
What should I do if I receive a Medicare discharge decision?
Once you receive a discharge decision and you are not ready to leave, you should immediately contact your local Medicare Quality Improvement Organization (QIO). A QIO is a group of doctors and other professionals who monitor the quality of care delivered to Medicare beneficiaries.
Are Medicare beneficiaries given timely notice of reasons for discharge?
The plaintiffs sought a requirement that Medicare beneficiaries are given timely written notice of the reasons for their discharge and of the procedures for appealing a discharge decision. As a result of settlement discussions, proposed regulations were published on April 5, 2006, at 71 Fed. Reg. 17052.
Is there a checklist to avoid premature discharge from hospital?
Many hospitals have checklists that must be followed to avoid premature discharge, but there are many individual factors that must be taken into account and that can’t be found on a checklist.
How can I avoid being discharged from the hospital?
Initiating an appeal. If you don't feel ready to leave the hospital, call the QIO and explain that you're filing a fast appeal of a pending discharge. You can call during the day or at night up until just before midnight on the day that the discharge was set to occur.
Can Medicare kick you out of the hospital?
Medicare covers 90 days of hospitalization per illness (plus a 60-day "lifetime reserve"). However, if you are admitted to a hospital as a Medicare patient, the hospital may try to discharge you before you are ready. While the hospital can't force you to leave, it can begin charging you for services.
Can you refuse a discharge?
Refusing a Proposed Discharge If you are unhappy with a proposed discharge placement, explain your concerns to the hospital staff, in writing if possible. Ask to speak with the hospital Risk Manager and let them know you are unhappy with your discharge plan.
How do I get a discharge appeal from Medicare?
Appeals with the best chances of winning are those where something was miscoded by a doctor or hospital, or where there is clear evidence that a doctor advised something and the patient followed that advice and then Medicare didn't agree with the doctor's recommendation.
Can you appeal a discharge?
Step 1: You Receive Notice of Termination/Discharge You may appeal if you disagree with the termination and — if the services are provided by an HHA or CORF — a doctor certifies that failure to continue the service may place your health at significant risk.
Who decides discharge from hospital?
While only a doctor can authorize your release from the hospital, the actual process of discharge planning can be carried out by a nurse in charge, discharge planner, social worker, case manager, or other professionals. Typically, discharge planning involves a team approach.
How long can you stay in the hospital under Medicare?
90 daysDoes the length of a stay affect coverage? Medicare covers a hospital stay of up to 90 days, though a person may still need to pay coinsurance during this time. While Medicare does help fund longer stays, it may take the extra time from an individual's reserve days. Medicare provides 60 lifetime reserve days.
Are patients being discharged too early?
Updated by David Goguen, J.D. A too-early discharge from a hospital or other care facility can cause as much harm as any other medical error committed by a health care professional. That means a situation like this can form the basis of a viable medical malpractice claim.
What to do if you feel the hospital is discharging you too soon?
If You Feel You're Being Discharged Too SoonSpeak up. “If you have concerns, if you don't feel heard, advocate until you find the right person to listen,” Brinker says. ... Go up the chain of command. ... Ask Medicare to delay your discharge. ... Enlist the hospital's patient advocate. ... Use language that providers connect with.
What should I say in a Medicare appeal?
Explain in writing on your MSN why you disagree with the initial determination, or write it on a separate piece of paper along with your Medicare Number and attach it to your MSN. Include your name, phone number, and Medicare Number on your MSN. Include any other information you have about your appeal with your MSN.
What percentage of Medicare appeals are successful?
For the contracts we reviewed for 2014-16, beneficiaries and providers filed about 607,000 appeals for which denials were fully overturned and 42,000 appeals for which denials were partially overturned at the first level of appeal. This represents a 75 percent success rate (see exhibit 2).
How do I fight Medicare?
Fill out a "Redetermination Request Form [PDF, 100 KB]" and send it to the company that handles claims for Medicare. Their address is listed in the "Appeals Information" section of the MSN. Or, send a written request to company that handles claims for Medicare to the address on the MSN.
How to Fight a Hospital Discharge with Medicare
Hospitalization is by definition a traumatic experience for most patients. Fortunately, Medicare covers 90 days of hospitalization per illness in addition to a 60-day lifetime reserve. That said, it is not uncommon for hospitals to try and discharge Medicare patients before they are ready, primarily as a means of saving the hospital money.
Contact the Quality Improvement Organization (QIO)
As long as you contact your local QIO by noon on the first business day after receiving your hospital discharge notice, you will be exempt from paying for your care while the discharge order is reviewed.
When would a hospital discharge take place?
In an ideal world, hospital discharge would take place when both you and your doctor think the time is right. You would be strong enough and healthy enough to handle not only the important discharge tasks and details, but also to take care of yourself once you arrive at your destination.
What is hospital discharge?
About the only aspect of leaving a hospital that is consistent among all patients is that we all do it sooner or later. Hospital discharge is the process by which you prepare to leave the hospital . Morsa Images / DigitalVision / Getty Images.
What is a QIO in Medicare?
The person you will be appealing to is called the Quality Information Officer (QIO). The federal government has strict requirements for the way a QIO handles discharge appeals. 2 . Ask about the "Safe Discharge" policy . Safe discharge is the key term Medicare uses, and you can use it, too.
How long does Medicare pay for skilled nursing?
For example, if you need to be discharged to a skilled nursing center or rehab, Medicare won’t pay for it unless you’ve stayed at least three days. So you may be caught in a bind. What is wrong with you—based on your diagnostic code—may mean they’ll pay for only two days.
What should a hospital admittance include?
Your hospital admittance should include a statement of your rights along with discharge information and how to appeal a discharge. If you aren’t provided with a notice of discharge and how to file an appeal, request one from the hospital's patient advocate and follow those guidelines. Talk to the QIO.
Does the hospital send you home if you don't pay?
Based on the anticipated codes that have been assigned to you, once your time is up, your payer will no longer pay for your stay. If they won’t pay, then unless you can pay cash, the hospital will send you home. Therefore, your date and time of discharge are not based on physical readiness.
Can you appeal a hospital decision if you are not a Medicare patient?
Medicare has a very specific process to follow no matter where you live or what hospital you’ve been admitted to. Those guidelines may also be used by the hospital for non-Medicare patients, so if you decide to appeal and you aren’t a Medicare patient, you can attempt to try to follow their instructions anyway.
How long before discharge do you have to sign a copy of your IM?
Information on your right to get a detailed notice about why your covered services are ending. If the hospital gives you the IM more than 2 days before your discharge day, it must give you a copy of your original, signed IM or provide you with a new one (that you must sign) before you're discharged.
What is your right to be involved in a hospital decision?
Your right to be involved in any decisions that the hospital, your doctor, or anyone else makes about your hospital services and to know who will pay for them. Your right to get the services you need after you leave the hospital. Your right to appeal a discharge decision and the steps for appealing the decision.
What is BCMP in Medicare?
The Beneficiary Care Management Program (BCMP) is a CMS Person and Family Engagement initiative supporting Medicare Fee-for-Service beneficiaries undergoing a discharge appeal, who are experiencing chronic medical conditions requiring lifelong care management. It serves as an enhancement to the existing beneficiary appeals process. This program is not only a resource for Medicare beneficiaries, but extends support for their family members, caregivers and providers as active participants in the provision of health care delivery.
What is coinsurance in Medicare?
An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%). The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.
Can you leave a hospital before the BFCC-QIO decision?
The hospital can't force you to leave before the BFCC-QIO reaches a decision. Within 2 days of your admission and prior to your discharge, you should get a notice called "An Important Message from Medicare about Your Rights.". This notice is sometimes called the Important Message from Medicare or the IM.
Does Medicare cover hospital admissions?
Medicare will continue to cover your hospital stay as long as medically necessary (except for applicable coinsurance or deductibles) if your plan previously authorized coverage of the inpatient admission, or the inpatient admission was for emergency or urgently needed care.
Who should contact if a Medicare discharge is too soon?
Medicare beneficiaries and their advocates who question the appropriateness of a proposed discharge from a Medicare hospital, whether the discharge is too soon or whether necessary post-hospital services have been arranged, should contact the local Quality Improvement Organization ( QIO) and file a complaint.
Why is discharge planning important?
This is particularly important when the beneficiary (or client)_feels that the discharge is inappropriate for any reason. Similarly, good discharge planning for patients, their families, and their healthcare providers, paves the way to successful transitions from one care setting to another.
What information is useful for Medicare beneficiaries and their advocates?
The following information for Medicare beneficiaries and their advocates is useful in challenging a discharge or reduction in services in the hospital, skilled nursing, home health, or hospice care setting: Carefully read all documents that purport to explain Medicare rights.
How long is an outpatient observation in Medicare?
Medicare beneficiaries throughout the country are experiencing the phenomenon of being in a bed in a Medicare-participating hospital for multiple days, sometimes over 14 days, only to find out that their stay has been classified by the hospital as outpatient observation. In some instances, the beneficiaries’ physicians order their admission, but the hospital retroactively reverses the decision. As a consequence of the classification of a hospital stay as outpatient observation (or of the reclassification of a hospital stay from inpatient care, covered by Medicare Part A, to outpatient care, covered by Medicare Part B), beneficiaries are charged for various services they received in the acute care hospital, including their prescription medications. They are also charged for their entire subsequent SNF stay, having never satisfied the statutory three-day inpatient hospital stay requirement, as the entire hospital stay is considered outpatient observation. The observation status issue has been challenged in Bagnall v. Sebelius (No. 3:11-cv-01703, D. Conn), filed on November 3, 2011. Litigation is ongoing. For updates, see https://www.medicareadvocacy.org/bagnall-v-sebelius-no-11-1703-d-conn-filed-november-3-2011/ (site visited May 27, 2015).
When a hospital determines that inpatient care is no longer necessary, the Medicare beneficiary has the right to request an
When a hospital (with physician concurrence) determines that inpatient care is no longer necessary, the Medicare beneficiary has the right to request an expedited QIO review. The CMS guidelines provide that the appeal for expedited review must be made before the beneficiary leaves the hospital.
How to contact Medicare for Elder Care?
In addition, contact the Medicare program’s information line: 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048 for the hearing impaired).
When is an ABN required for Medicare?
When a beneficiary is placed in observation status by the attending physician, it is not clear whether the hospital is required to give the patient an Advance Beneficiary Notice (ABN) of non-coverage in order to shift liability to the beneficiary. If the service is a Part B service, but it “falls outside of a timeframe for receipt of a particular benefit,” then the hospital must give the beneficiary an ABN. See Medicare Benefit Policy Manual, CMS Pub. 100-02, Chapter 6, §20.6.C.
How long does it take for Medicare to decide on a rehab appeal?
Decisions are typically made within 72 hours, and while the appeal is pending, Medicare continues to cover rehab costs. Even if Medicare determines that the patient no longer qualifies for coverage, the patient still has a right to the bed in the rehab facility.
Can a nursing home stay in a nursing home if Medicare coverage discontinues?
In fact, a nursing home resident has the right to remain in the facility even if Medicare coverage discontinues. Being discharged early. The reasons for this vary, but in many cases nursing homes choose to discharge rehab patients based on their assessment that the patient has plateaued.
What is a MOON in Medicare?
Medicare Outpatient Observation Notice (MOON) Hospitals and CAHs are required to provide a MOON to Medicare beneficiaries (including Medicare Advantage health plan enrollees) informing them that they are outpatients receiving observation services and are not inpatients of a hospital or critical access hospital (CAH).
How long does a hospital have to issue a notice to enrollees?
As under original Medicare, a hospital must issue to plan enrollees, within two days of admission, a notice describing their rights in an inpatient hospital setting, including the right to an expedited Quality Improvement Organization (QIO) review at their discharge. (In most cases, a hospital also issues a follow-up copy of this notice a day or two before discharge.) If an enrollee files an appeal, then the plan must deliver a detailed notice stating why services should end. The two notices used for this purpose are:
When does a plan issue a written notice?
A plan must issue a written notice to an enrollee, an enrollee's representative, or an enrollee's physician when it denies a request for payment or services. The notice used for this purpose is the:
What is a CMS model notice?
CMS model notices contain all of the elements CMS requires for proper notification to enrollees or non-contract providers, if applicable. Plans may modify the model notices and submit them to the appropriate CMS regional office for review and approval. Plans may use these notices at their discretion.