One of the major benefits of Medicare is its coverage of hospitalization. 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. Therefore, it is important to know your rights and how to appeal. Even if you don't win your appeal, appealing can buy you crucial extra days of Medicare coverage.
Medicare requires hospitals to give Medicare patients information about their discharge and appeal rights. The rules require hospitals to give two notices to patients of their rights -- one right after admission and one before discharge. Within two days of admission to a hospital, the hospital must give you a notice called "An Important Message from Medicare about Your Rights" (IM) explaining your discharge and appeal rights. You must read the notice, sign it, and date it. Two days before discharge, the hospital must give you another copy of the IM. If you are in the hospital for three days or less, the hospital only needs to give you one notice.
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. They are paid by the federal government and not affiliated with a hospital or HMO. The phone number should be on the IM.
It is very important to contact the QIO right away. You must contact the QIO by noon on the first business day after you receive the discharge notice. If you do this, you will not have to pay for your care while you wait for your discharge to be reviewed. If you don't contact the QIO by noon, the hospital can begin charging you on the third day after you receive the discharge notice.
Once you request a QIO review, the hospital is required to give you a "Detailed Notice of Discharge." You should receive the notice no later than noon the day after you request a QIO review. The detailed notice explains the medical reason behind the discharge.
The QIO will conduct a review of the discharge. The QIO doctors will review the medical necessity, appropriateness, and the quality of hospital treatment furnished to you. The hospital cannot discharge you while the QIO is reviewing the discharge decision, and you will not have to pay for the additional days in the hospital. If you don't agree with the QIO's decision, you can ask it to reconsider. It must issue a decision within three days.
Although most QIO decisions agree with the hospital, asking for QIO review often makes sense because the process itself can often add a day or two of Medicare coverage. You are more likely to get two days of additional coverage if you wait until the morning of the day after you receive the notice to contact the QIO -- but make sure you do it before noon. Also, the QIO review may take a bit longer over a weekend. So a patient who receives a notice on a Thursday requiring discharge by Friday often can extend Medicare coverage until noon on Monday by seeking QIO review on Friday morning.
If, after the reconsideration, the QIO still agrees with the hospital's decision, you can appeal to an administrative law judge (ALJ). You will probably need legal counsel to help you through this process. You can appeal the ALJ's decision to the Department of Health and Human Services, Departmental Appeals Board (DAB). Finally, if you don't agree with the DAB decision, you can appeal to federal court as long as at least $1,000 is at stake.
States may have their own discharge protections. You can find the law in your state from the QIO in your state. Click here for a list of QIOs by state.