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”).
If you’re admitted to a hospital as a Medicare patient, the hospital may try to discharge you before you’re 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.
Hospitals must 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). It explains 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.
If you receive a discharge decision but are not ready to leave, contact your local Medicare Quality Improvement Organization (QIO) immediately. A QIO is a group of doctors and other professionals who monitor the quality of care delivered to Medicare enrollees. The federal government pays them. They’re not affiliated with a hospital or HMO.
The phone number you will need to call should appear on the IM paperwork.
Contact the QIO Right Away
Contact the QIO by noon on the first business day after you receive the discharge notice. This way, you will not have to pay for your care while you wait for the QIO to review your discharge. If you don’t contact them 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 must 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. 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.
Most QIO decisions agree with the hospital. However, asking for QIO review makes sense because the process can often add a day or two of Medicare coverage. You’re 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 do it before noon.
The QIO review may take a bit longer over a weekend. If you receive notice on Thursday for discharge by Friday, you often can extend Medicare coverage until noon on Monday by seeking QIO review Friday morning.
If the QIO still agrees with the hospital, you can appeal to an administrative law judge. Consider legal counsel to help with this process. You can appeal the judge’s decision to the Department of Health and Human Services, Departmental Appeals Board. If you disagree with the board, you can appeal to federal court (as long as at least $1,000 is at stake).