You are notified that you will be discharged from the hospital this afternoon. But you are concerned that your discharge is taking place too soon. You think you need additional in-patient care in the hospital. What can you do? Can you stop your scheduled discharge?
Hospital discharges don’t always take place at the ideal time. You can be notified that you are being discharged before you think you are ready. If you find yourself in this situation Medicare provides a relatively simple appeal process for hospitalized beneficiaries to use to delay their discharge while its appropriateness is reviewed.
If you think you or your loved one is not ready for discharge, you can file an expedited “fast” appeal. The hospital is required to give you a notice that contains the information you need to file this appeal. The notice you should receive is called the ”Important Message from Medicare” [IM] notice. The IM form was updated in June 2017 and a copy is available here.
You and your representative should read your IM notice carefully. It tells you that you have the right to appeal your planned discharge if you have concerns about it. The appeal will involve a review of your case by a Quality Improvement Organization (QIO). The QIO (also called a BFCC-QIO) is an independent outside reviewer hired by Medicare to look at your case to decide whether you are ready to leave the hospital.
If you want to appeal, you must contact the QIO no later than your planned discharge date and before you leave the hospital. If you do this, you will not have to pay for the services you receive during the fast appeal (except for charges like copays and deductibles).
Page 2 of the IM notice form contains step by step instructions for calling the QIO and filing an appeal.
[This is one of a series of articles I have written on the topic of being discharged from a hospital. My other recent articles on this subject are: Preparing for your Hospital Discharge; and Preparing for your hospital discharge (Part 2)]
Medicare regulations require that the IM form be given to hospital in-patients at or near the time of their admission, but no longer than 2 calendar days following admission. If you don’t receive it, ask for it. If you still don’t receive it, the Medicare website has the information you need to file a fast appeal for yourself or your hospitalized loved one. http://tinyurl.com/zrl3zks.
After you file your fast appeal, you should receive a detailed notice from the hospital (or your Medicare Advantage or other Medicare managed care plan if you belong to one) that explains the reasons they think you are ready to be discharged. The QIO will ask for your opinion. You (or your representative) need to be available to speak with the QIO, if requested. You (or your representative) may give the QIO a written statement, but you are not required to do so.
The QIO will notify you of its decision within 1 day after it receives all necessary information. If the QIO finds that you are not ready to be discharged, Medicare will continue to cover your hospital services. If the QIO finds you are ready to be discharged, Medicare will continue to cover your services only until noon of the day after the QIO notifies you of its decision
The fast appeal is only the initial step in a potential series of appeals you can file. But the fast appeal may be only step you will need to take. At the very least, it will buy you some time at minimal or no cost to you. Don’t be shy about using this process – getting a QIO review of your discharge is your right.
As good brief overview of the fast appeal process is available here.
Here are a couple of other points to note about fast appeals:
- A second follow-up copy of the IM notice is supposed to be given to you no more than 2 calendar days prior to your discharge. However, the follow-up notice may not be required if the time between your admission and the proposed discharge is short.
- You QIO’s telephone number should be listed on the IM notice you receive. If you don’t have it you can get the QIO’s phone number by visiting Medicare.gov/contacts or calling 1-800-MEDICARE (1-800-633-4227). TTY users should call1-877-486-2048.
- The hospital has the burden of proving the appropriateness of your planned discharge and must justify it to the QIO. The discharge can be justified either on the basis of lack of medical necessity or on Medicare coverage policies.
- If you win the fast appeal – the QIO disagrees with the hospital’s decision to discharge you – your Medicare covered stay can continue;
- On the other hand, if the QIO issues a decision which agrees with the hospital’s decision to discharge you, you have the right to file another appeal – called a “Request for Reconsideration.” You must file this Request by noon of the day after you receive the initial QIO’s decision. Note, however, that you may become financially responsible for the full cost of care you receive starting as of noon of the day you received the QIO’s negative initial decision.
- The fast appeal process applies whether you are enrolled in original Medicare or in a Medicare Advantage plan. For Medicare Advantage plans see the regulation regarding beneficiary notice of discharge rights at 42 C.F.R. §§422.620, For more information on appeal rights from Medicare Advantage plans see the Medicare website here and here. If you have coverage through Programs of All-inclusive Care for the Elderly (PACE), which are referred to as “LIFE” programs in Pennsylvania, your appeal rights are different. The PACE organization should provide you with written information about your appeal rights.
- Fast appeal rights apply to beneficiaries who have been admitted as hospital in-patients. But you may be in the hospital on “observation status” rather than as an in-patient. The hospital should provide you with notice if you are in observation status. For more information regarding the problems related to observation vs. in-patient status see FAQ: Hospital Observation Care Can Be Costly For Medicare Patients; and see my earlier article Hospital Patients to Receive Notice of Observation Status.
Before you file your fast appeal, try to talk with the physician involved and/or with the hospital discharged planner assigned to your stay. Tell them why you think you are not ready to be discharged and ask them to reconsider the discharge decision. Feel free to them that you are planning on filing a fast appeal. But be sure not to delay so long that you fail to initiate your appeal within the time required. Contact the QIO no later than your planned discharge date and before you leave the hospital.
Medicare Appeals (Centers for Medicare and Medicaid Services)
Getting a fast appeal in a hospital (Medicare.gov)
Discharge Planning (Center for Medicare Advocacy)