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’re admitted to a hospital as a Medicare patient, the hospital might 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’s 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.
Within two days of admission to a hospital, the hospital must give you a notice called “An Important Message from Medicare about Your Rights,” which 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. If you’re in the hospital for three days or less, the hospital only needs to give you one notice.
If you receive a discharge decision but you’re not ready to leave, you should immediately contact your local Medicare Quality Improvement Organization and request a review. This Organization 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 are not affiliated with a hospital or HMO. The phone number should be on the “Important Message.”
You must contact the Organization by noon on the first business day after you receive the discharge notice. If you do this, you won’t have to pay for your care while you wait for your discharge to be reviewed. If you don’t contact the Organization by noon, the hospital can begin charging you on the third day after you receive the discharge notice.
Once you request a review by the Organization, the hospital is required to give you a “Detailed Notice of Discharge.” You should receive this notice no later than noon on the day after you request the review. The detailed notice explains the medical reason behind the discharge.
In the review, the Organization’s doctors will evaluate the medical necessity, appropriateness, and quality of hospital treatment furnished to you. The hospital cannot discharge you while the Organization is reviewing the discharge decision, and you won’t have to pay for the additional days in the hospital. The Organization must issue a decision within three days. If you don’t agree with the decision, you can ask it to reconsider.
If, after the reconsideration, the Organization still agrees with the hospital’s decision, you can appeal to an administrative law judge. You will probably need legal counsel to help you through this process. You can appeal the judge’s decision to the Department of Health and Human Services Departmental Appeals Board. Finally, if you don’t agree with that decision, you can appeal to federal court as long as at least $1,000 is at stake.
Some states have their own discharge protections. You can find out what the law in your state is from the Organization.