Takeaways
- Medicare patients have the right to appeal a hospital discharge decision. They must be informed of this right shortly after admission and again before discharge.
- To fight a discharge, you must immediately contact the Medicare Quality Improvement Organization (QIO) by midnight on the day of your scheduled discharge while you are still in the hospital for an expedited appeal.
- Appealing the discharge, even if unsuccessful, often buys the patient crucial extra days of Medicare-covered hospital care.
One major Medicare benefit is its coverage of hospitalization. Medicare Part A covers up to 90 days of hopsital care per benefit period (plus up to 60 “lifetime reserve” days). (Note that a benefit period resets after the patient has been out of the hospital or skilled nursing care for 60 consecutive days.)
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.
Patient Rights
Hospitals must provide Medicare patients with 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 go home, 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
If you want an expedited review of your hospital discharge, contact the QIO by midnight on the day of your scheduled discharge while you are still in the hospital. If you request the review on time, you are not financially responsible for the cost of covered hospital services while the QIO reviews the discharge decision. If you miss the deadline, you may become financially responsible for your hospital stay starting on the scheduled discharge date.
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 the hospital is notified of your appeal request. The detailed notice explains why the hospital believes your Medicare coverage should end and provides the medical and coverage reasons for 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.
QIOs often uphold the hospital’s discharge decision. However, requesting a timely expedited review can temporarily continue Medicare coverage while the QIO reviews the case. Remember, to protect your coverage, you must contacct the QIO by midnight on the day of your scheduled discharge while you are still in the hospital.
The QIO review may take longer over weekends. Filing your appel promptly ensures Medicare coverage continues while the review is pending.
If the QIO agrees with the hospital, you can continue appealing through Medicare’s standard appeals process, which includes review by a qualified independent contractor, a hearling before an administrative law judge, review by the Medicare Appeals Council, and potentially federal court. Consider legal counsel to help with this process.
Observation Stays: A Discharge Loophole
A key point for Medicare patients to understand is the difference between being an “inpatient” and being under “observation status.” Hospitals sometimes keep patients for days under observation status, even if they are in a hospital bed receiving treatment. Crucially, time spent under observation is not counted as part of the inpatient stay for Medicare purposes.
If you are discharged after an observation stay, you generally do not have the right to the expedited QIO hospital discharge appeal process described above, because that right applies to formal inpatient admissions. In addition, for people in Original Medicare, time spent under observation usually does not count toward the three-day inpatient stay required for Medicare to cover a subsequent skilled nursing facility stay. (Some Medicare Advantage plans may waive this requirement.) Always ask if you have been formally admitted as an inpatient.
Additional Resources
States may have their own discharge protections. You can find the law from the QIO in your state.
For further reading on topics related to Medicare, check out the following articles: