At the Association of Life Care Planning Lawfirms, one segment dealt with Medicare. The attorney who spoke, a specialist in Medicare law, commented that Medicare may have the most difficult set of rules that she has ever run into – and that is saying a lot.
One of the major benefits of Medicare is its coverage of hospitalization. Medicare covers up to 90 days of hospitalization per illness (plus a 60-day “lifetime reserve”). However, if you are admitted to a hospital as a Medicare patient, the hospital may try to discharge you before you are ready. While the hospital cannot force you to leave, it can begin charging you for services that are not covered by Medicare. Therefore, it is important to know your rights and how to appeal. Even if you do not win your appeal, appealing can buy you crucial extra days of Medicare coverage.
Starting July 1, 2007, a new notice requirement went into effect for Medicare patients being discharged from the hospital. The notices give Medicare patients information about their discharge and appeal rights.
Previously, hospitals were required to give patients a written notice before discharge called “Hospital- Issued Notice of Non-coverage” (HINN). The hospital may still give HINN’s in certain circumstances, but the new rules require hospitals to give two notices to patients of their rights – one right after admission and one before discharge.
The new laws require that 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) explaining your discharge and appeal rights. You are required to read the notice, sign it and date it. Two days before discharge, the hospital must give you another IM notice, but, for some reason, this one does not have to be signed. If you are in the hospital for three days or less, the hospital only needs to give you one notice. In such circumstances, the notice must be given within four hours of your discharge.
Once you receive a discharge decision, and if you are not ready to leave, you should immediately contact your local Medicare Quality Improvement Organization (QIO). A QIO is a group of doctors or 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 IM.
It is very important to contact the QIO right away. You must contact the QIO by noon on the first business day after you receive the discharge notice. If you do this, you will not have to pay for your care while you wait for your discharge to be reviewed. If you do not contact the QIO by noon, the hospital can begin charging you on the third day after you receive the discharge notice.
Once you receive the QIO’s review, the hospital is required to 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 reasons behind the discharge.
The QIO will conduct a review of the discharge. The QIO doctors will review the medical necessity, appropriateness, and quality of the hospital treatment furnished to you. The hospital cannot discharge you while the QIO is reviewing the discharge decision, and you will not have to pay for the additional days in the hospital. If you do not agree with the QIO’s decision, you can ask it to reconsider. It must issue a decision within three days.
If, after the reconsideration, the QIO agrees with the hospital’s decision, you can appeal to an administrative law judge (ALJ). You will probably need legal counsel to help you through this process. You can appeal the ALJ’s decision to the Department of Health and Human Services’ Department Appeals Board (DAB).
Finally, if you do not agree with the DAB’s decision, you can appeal to federal court as long as at least $1,000 is at stake.
If you are a resident of Kansas, you can get some assistance and more information by calling the Kansas Foundation for Medical Care at 1-800-432- 0407. Its website is www.kfmc.org.