Claire Dawson
If you feel that you are being discharged from a hospital too soon, you have the right to appeal the decision. The appeal process varies based on the kind of coverage you have, and there are separate processes for hospital and non-hospital appeals. If you are appealing a hospital discharge, you will need to file an appeal with your insurance provider. The steps for an appeal will vary from hospital to hospital and from state to state, except in the case of Medicare, which has a specific process to follow no matter where you live or what hospital you've been admitted to.
| Characteristics | Values |
|---|---|
| When to appeal | Within 2 days of admission and prior to discharge |
| Who can appeal | Medicare beneficiaries who think their services are ending too soon |
| How to appeal | Follow the directions on the "Important Message from Medicare" |
| Where to appeal | To the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) |
| What to submit | Medical records, a letter from your doctor, or other relevant information |
| Deadlines | Midnight of the day of discharge |
| Costs | The beneficiary is only responsible for coinsurance and deductibles |
| Levels of appeal | 5 levels, with only the first 2 being expedited |
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What You'll Learn
Understanding your rights as a patient
Right to Information: You have the right to receive clear and timely information about your healthcare, including your medical condition, treatment options, and any changes in your care plan. Before discharging you, the hospital must provide you with a written notice explaining your rights, known as the "Important Message from Medicare about Your Rights" (IM). This notice should be provided within two days of your admission and before your discharge. It will explain your right to appeal and the steps you can take if you disagree with the discharge decision.
Right to Appeal: If you believe you are being discharged from the hospital prematurely, you have the right to appeal that decision. You can request an expedited or ""fast"" appeal to challenge the early discharge. This process allows you to seek continued care while your appeal is being reviewed. It is important to follow the instructions provided in the IM and submit your appeal within the specified timeframe.
Right to be Involved in Decision-Making: As a patient, you have the right to be involved in decisions regarding your healthcare. This includes having a say in your treatment plan, discharge, and any post-discharge services you may require. You can request a second opinion or an in-hospital consultation with a specialist if you disagree with the initial decision. Your healthcare providers should work with you to address your concerns and make decisions that are in your best interests.
Right to Continuity of Care: When your hospital care ends, you have the right to receive the necessary services and support after your discharge. This includes access to follow-up treatments, medications, and any other services required for your ongoing care. Understanding your post-discharge rights can help ensure a smooth transition and prevent gaps in your healthcare coverage.
Right to a Fair and Transparent Appeals Process: The appeals process for Medicare discharges is designed to be fair and transparent. There are typically five levels of appeals, and you have the right to move to the next level if you disagree with a decision. At each level, you will receive a decision letter with instructions on how to proceed. Additionally, you have the right to request information from your provider or supplier to strengthen your appeal.
Remember, it is important to carefully review the information provided by the hospital, understand your rights, and take timely action if you need to appeal a discharge decision. By understanding your rights as a patient, you can advocate for yourself and ensure you receive the care you need.
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How to request a fast appeal
If you believe your Medicare-covered health care services are ending too soon or you're being discharged from a hospital or skilled nursing facility prematurely, you have the right to request an expedited, or "fast," appeal. This allows you to fast-track challenges to decisions about Medicare-covered services.
- Notice of Medicare Non-Coverage: You should receive a notice called "Notice of Medicare Non-Coverage" at least two days before your covered services end. If you don't receive this notice, ask your provider for it. This notice will inform you of your right to a fast appeal and provide information on how to contact the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) in your state.
- Important Message from Medicare: Within two days of your admission and before your discharge, you should also receive a notice called "An Important Message from Medicare about Your Rights." This notice will explain your patient rights and inform you of how to file an expedited appeal if you disagree with the hospital's discharge decision.
- Contact the BFCC-QIO: Contact the BFCC-QIO in your state. You can find their contact information in the "Important Message from Medicare" notice. You can file your appeal by telephone or in writing.
- Submit Supporting Documentation: Along with your appeal, submit any relevant medical records or letters from your doctor or healthcare provider that support your request for continued care.
- Detailed Explanation of Non-Coverage: After you file your appeal, the hospital or healthcare provider will send you and the BFCC-QIO a "Detailed Explanation of Non-Coverage," explaining why your services are ending and providing information on applicable Medicare coverage rules.
- Decision and Financial Considerations: The BFCC-QIO will decide whether your covered services should continue. If you meet the deadline for requesting a fast appeal, Medicare may cover some hospital charges, depending on the decision and the timing of your discharge.
It is important to carefully review the notices provided by your healthcare provider and follow the instructions and timelines outlined in the "Important Message from Medicare" and "Notice of Medicare Non-Coverage" to ensure a timely and effective appeal process.
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The role of a Quality Improvement Officer (QIO)
If you disagree with a hospital's decision to discharge you or a loved one, you may be able to appeal to a Quality Improvement Officer (QIO). The QIO is an independent reviewer who assesses whether your services should continue.
The role of a QIO is to review a hospital's decision to discharge a patient. They are an independent reviewer, and their role is to assess whether a patient's services should continue. If you are appealing to a QIO, the hospital must send you a Detailed Notice of Discharge, which explains why your hospital care is ending and lists any Medicare coverage rules related to your case. The QIO will request copies of your medical records from the hospital.
To initiate the process, you should receive a notice titled "Important Message from Medicare" within two days of being admitted as an inpatient. This notice explains your rights as a patient, and you will be asked to sign it. If your inpatient hospital stay lasts three days or longer, you should receive another copy of the same notice before you leave the hospital, no later than four hours before you are discharged. This notice tells you how to file an expedited appeal to the QIO.
If you ask for your appeal within this time frame, you can stay in the hospital while you wait for the QIO's decision. You won't have to pay for your stay (except for applicable coinsurance or deductibles). If you miss the deadline for a fast appeal, you can still request a fast reconsideration from your plan, but different rules and time frames will apply, and you may be responsible for the cost of your hospital stay beyond the original discharge date.
It is important to note that the appeal process varies based on the kind of coverage you have. There are generally five levels of appeals, and you can usually proceed to the next level if you disagree with the decision at any level.
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Appealing a decision about non-hospital services
If you are an inpatient at a hospital, you should receive a notice titled "Important Message from Medicare" within two days of being admitted as an inpatient. This notice explains your rights as a patient, and you should receive another copy up to two days before you are discharged. If you disagree with the hospital’s discharge decision, this notice tells you how to file an expedited appeal to the Quality Improvement Organization (QIO).
If you are appealing to the QIO, the hospital must send you a "Detailed Notice of Discharge". This notice explains in writing why your hospital care is ending and lists any Medicare coverage rules related to your case. The QIO will request copies of your medical records from the hospital.
If you decide to stay in the hospital during the appeals process and the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) agrees with the original decision to change your status, you’ll be responsible for payment of services you get during the appeal process. If they decide your services are ending too soon, Medicare may continue to cover your skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility (CORF), or hospice services (except for applicable coinsurance or deductibles).
If you miss the deadline for a fast appeal, you can still ask the BFCC-QIO to review your case, but different rules and time frames apply, and you might be responsible for the cost of the hospital stay past the original day the hospital tries to discharge you. If you're in a Medicare Advantage Plan, you can ask your plan for an appeal, but different rules apply.
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What to do if your appeal is denied
If your appeal is denied, you can still request a fast reconsideration from your plan. However, services will only be covered if the decision is issued in your favour. If you have a Medicare health plan, the BFCC-QIO will notify your plan and the hospital. By noon the day after the notification, the hospital will give you a "Detailed Notice of Discharge". This notice will include a description of the applicable Medicare coverage rules or policies and information on how you can get a copy of the policy.
If you are appealing to the QIO, the hospital must send you a "Detailed Notice of Discharge". This notice explains in writing why your hospital care is ending and lists any Medicare coverage rules related to your case. The QIO will request copies of your medical records from the hospital.
There are generally five levels of appeals, and you can usually move to the next level if you disagree with the decision made at the current level. You will receive a decision letter with instructions on how to move forward with the next level of appeal. If you are denied coverage by Medicare for a health service or item, you have the right to appeal the decision. You can file a Medicare coverage denial appeal yourself, or you can contact your local SHIP for help.
If you have already received the care that is being denied, you should have the denial on your EOB. An appeal of this decision is called a "post-service appeal". If the denial is for a service or item that you have not yet received, you should get a "Notice of Denial of Medical Coverage" from your plan. An appeal of this decision is called a "pre-service appeal". You can request an expedited appeal if the matter is urgent and your health could be seriously harmed by waiting for the standard timeline.
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Frequently asked questions
If you believe you are being discharged from a hospital too soon, you have the right to request an expedited or "fast" appeal. This involves challenging decisions about Medicare-covered services. You can file your appeal by telephone or in writing. You'll find the name and phone number of the BFCC-QIO (Beneficiary and Family Centered Care-Quality Improvement Organization) for your area in your IM (Important Message from Medicare).
You should receive the IM within two days of your admission to the hospital. The hospital must also give you a copy of the IM you signed within two days of your scheduled discharge date. You need to have this document to file your expedited Medicare appeal. If you miss the deadline for a fast appeal, you can still ask the BFCC-QIO to review your case, but different rules and timeframes will apply, and you might be responsible for the cost of the hospital stay past the original discharge date.
You can submit medical records or a letter from your doctor or other healthcare provider supporting your appeal. You will need to provide a rationale to your insurance provider and may need to fight the hospital to stay. You will need a healthcare provider to explain why an extended stay is a medical necessity.
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