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Appealing early hospital discharge decisions

Medicare

It doesn’t take much for the life of an independent person to come to a screeching halt. A fractured, hip, leg, wrist, arm, shoulder or replaced knee is all it takes to make you depend on the support of others to do everyday tasks. The problem is that Medicare has a stringent set of rules about when it will approve hospital stays and rehab – which sometimes leads to early hospital discharges and often results in additional health complications. Here’s what you need to know to ensure a safe discharge.

 

Stringent rules

 

Medicare now has stringent criteria for hospital admissions, which has many people being discharged earlier than they are able to care for themselves at home. Complicating matters, Medicare also has a “three-day rule” requiring beneficiaries to have spent three days in a hospital before Medicare will pay for skilled nursing care. These rules are having a detrimental effect on care – and on the costs of caring for patients. “The whole point of Medicare paying for skilled care was to reduce lengths of stay in hospitals once a person has recovered but remained an inpatient because they were not strong enough to go home,” says Dr. John Messmer, a family practice physician and geriatrician in New York.

 

“Times have changed, and we have the ability to treat many problems in the outpatient arena that would have been hospitalizations in the past. Medicare must adapt and allow direct transfers to a skilled facility with healthcare coverage when that level of care is needed,” Messmer continues. “If that happened, we would not turn away the thousands of people who do not meet InterQual (Medicare) criteria for admission. Nor would physicians have to increase the level of intensity of treatment just to prove the admission was needed. In the long run, I think it would save money for Medicare.”

 

The danger of going home too soon

 

Consider Joanne, who believes her hospital stay was too short following her admission for a stroke. “I wasn’t ready to go home but they told me there wasn’t anything else they could do for me,” Joanne says.
 

Since she hadn’t met Medicare’s “three-day rule” and couldn’t afford skilled care in a facility, she went home to receive visits from homecare agencies that were covered by Medicare. But within 48 hours she lost her balance at home, fell and broke her shoulder. The break required extensive surgery. And now, besides seeing a speech therapist for her stroke, she’s in rehabilitative care for a grueling shoulder replacement recovery.
 

Clearly, this approach did not save Medicare money. Of course, the price Joanne is paying defies a number.

 

Appealing Medicare decisions and premature hospital discharge

 

Joanne is only one of thousands of people each year discharged too soon. So let’s look at how you can appeal a hospital's early discharge.

 

  1. Be vocal about your right to a “safe discharge.” It’s important to note that Medicare beneficiaries have the right to a “safe discharge.” Sending someone home alone or into a situation where she will not receive adequate care because, for instance, her spouse has significant health problems, is not considered a safe discharge. So be sure to let the physician and discharge planners know of your circumstances. If you think you are being discharged too soon, talk with your doctor first to see whether the date can be changed. If not, you have the right to appeal the discharge date.

 

  1. Start the appeal process by calling the Quality Improvement Organization. Contact the Quality Improvement Organization (QIO) no later than your planned discharge date. The QIO is an outside reviewer hired by Medicare to assess your case and determine whether you are ready to leave the hospital. You should have received the QIO’s contact information and a document outlining your rights (“An Important Message from Medicare About Your Rights”) when you were admitted to the hospital. You can contact QIO any day of the week. Once you speak to someone or leave a message, your appeal has begun. To learn more about the discharge process and your rights, get in touch with your local QIO. A state-by-state directory can be found here.

 

  1. Provide the QIO with your opinion on the discharge materials. You will receive a notice from the hospital or Medicare Managed Care plan (should you belong to one) that explains why it has been decided you can be discharged. The QIO will then ask for your opinion; you or a representative can talk with QIO’s representative or submit a written statement.

 

  1. Receive notification from the QIO. QIO will review your statements and medical records regarding your case and will notify you of its decision one day after it has received the necessary information to review it. If the QIO determines that you are not ready for discharge, Medicare will continue to cover your services. If it disagrees, then Medicare will continue to cover your services until noon of the day after the QIO notified you of its decision.

 

Appealing discharges from a skilled nursing or rehab facility

 

Life isn’t a picnic for those who end up in a skilled nursing facility. While many of them are anxious to get home – usually to care for an ailing spouse – they worry about money and when “Medicare is going to tell them to get out.” Nearly every day, they hear of another fallen comrade who’s been told, “You’re good to go” because the criteria set by Medicare for rehabilitation care has been met. They live in a rehab limbo of wanting to do well but not too well and fear of not doing well enough, as both will induce Medicare to shorten their rehab stay.

 

The good news is that Medicare also provides appeal rights for other healthcare providers that give notice that they plan to discontinue your care, including skilled nursing facilities (nursing homes), homecare agencies, comprehensive outpatient rehabilitation centers and hospice.

 

Once you make the appeal, following the process above, your care will be covered while the QIO is reviewing the case. This process can gain up to two days of care while the case is being reviewed. Remember: even if the QIO decides that the discharge is valid, your hospital stay will be covered during the time it took to review the case and up to noon of the day following its notification to you of their decision.

 

The lesson:  if you believe that you or a loved one isn’t ready to leave or the discharge isn’t safe, make the call. It’s too bad so many people have to fight for their care as much as they have to fight to get well.

 

“As physicians, we’re taught to look out for the best interests of our patients. And now the system that was designed to help them has become a barrier to that help,” Messmer laments.

 

The bottom line

  • Medicare now has stringent criteria for hospital admissions, as well as a “three-day rule” requiring beneficiaries to have spent three days in a hospital before Medicare will pay for skilled nursing care. This leads to early discharges and often results in additional health complications, but there are things you can do to appeal Medicare coverage decisions.
  • Patients who go home too soon are often too weak to care for themselves at home, often resulting in injuries that delay and/or complicate the original reason for hospitalization and delays recuperation. If you think your parent is being discharged too soon, it’s very important to appeal the decision.
  • Appeal a discharge decision by contacting the Quality Improvement Organization (QIO), an outside reviewer hired by Medicare to assess your case and determine whether you are ready to leave the hospital, before your discharge date. To learn more about the discharge process and your rights, find your local QIO here.
  • The QIO will ask you questions and review medical records to make its decision about the discharge. Meanwhile, Medicare will cover your hospital stay until noon the day after the QIO renders its decision (if it agrees with the discharge).
  • Medicare also provides appeal rights for other healthcare providers that give notice that they plan to discontinue your care, including skilled nursing facilities (nursing homes), homecare agencies, comprehensive outpatient rehabilitation centers and hospice.
     
 
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