If you or a loved one are receiving in-patient medical care, there comes a time when that care will end. Hopefully, this is because the patient is ready for discharge, but sometimes, the patient is notified that care will be discontinued, possibly due to a notice from Medicare. You have a right to appeal this decision.
What if my medical care ends too soon?
If you are receiving care in a hospital or non-hospital setting and you learn that your care is going to end, you have the right to a fast, or expedited, appeal to request continued care. The distinction between hospital and non-hospital settings is made in these materials because there are different steps in the appeal process depending on whether hospital or non-hospital care is ending.
Note that hospital and non-hospital settings can overlap. For example, a hospital building may also include a skilled nursing facility. Although they are in the same building, the type of care they provide is different.
In both hospital and non-hospital settings you can file an appeal to challenge your provider’s decision to end your care if you think that they are wrong about whether Medicare will cover your services. If you are unable to appeal, a family member or other representative can appeal for you. If your appeal is unsuccessful at the first level, you can continue to appeal by following instructions on the denial notices you receive.
Expedited appeals have tight deadlines, so it is important to pay attention to the timeframes for appealing at each level. Keep copies of any appeal paperwork you send out, and if you speak to someone on the phone, get their name and write down the date and time that you spoke to them. It is helpful to have all of your appeal documents together in case you run into any problems and need to access documents you already mailed.
What notice(s) will I receive?
If you are an inpatient at a hospital, you should receive a notice titled ”Important Message from Medicare” within two days of being admitted. This notice explains your patient rights, 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. This notice should arrive up to two days, and no later than four hours, before you are discharged.
If your care is ending in a non-hospital setting, such as at a skilled nursing facility (SNF), comprehensive rehabilitation facility (CORF), hospice, or home health agency, because your provider believes Medicare will not pay for it, you should receive a “Notice of Medicare Non-Coverage.” You should get this notice no later than two days before your care is set to end. If you receive home health care, you should receive the notice on your second to last care visit. If you have reached the limit in your care or do not qualify for care, you do not receive this notice and you cannot appeal.
How do I start an appeal while in-patient at a hospital?
If the hospital says you must leave and you disagree, follow the instructions on the “Important Message from Medicare” to file an expedited appeal to the Beneficiary and Family Centered Care—Quality Improvement Organization (BFCC-QIO); currently for Alaska, this is Kepro —with contact details on the received notice. You must appeal by midnight (local time) on the day of your discharge. If you are appealing to the BFCC-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 BFCC-QIO will request copies of your medical records from the hospital. It can be helpful to ask the hospital for your own copy (a copying charge may apply). The BFCC-QIO will usually call you to get your opinion on the discharge, but you can also send a written statement.
The BFCC-QIO should call you with its decision within 24 hours of receiving all the information it needs. If the appeal to the BFCC-QIO is successful, your care will continue to be covered. If the BFCC-QIO decides that your care should end, you will be responsible for paying for any care you receive after noon of the day after the BFCC-QIO makes its decision. If you stay in the hospital after that period, you may be responsible for the cost of your care, unless you successfully appeal to a higher level of appeal.
If you leave the hospital or miss the deadline to file an expedited appeal to the BFCC-QIO, you have 30 days from your original discharge date to request a post-service BFCC-QIO review. The BFCC-QIO will send a written decision letter once it receives all the information it needs from you and the hospital.
How do I start an appeal for non-hospital care that is ending?
If you learn that your non-hospital care is ending and you feel that your care should continue, follow the instructions on the “Notice of Medicare Non-Coverage” to file an expedited appeal with the Quality Improvement Organization by noon of the day before your care is set to end. Once you file the appeal, your provider should give you a “Detailed Explanation of Non-Coverage.” This notice explains in writing why your care is ending and lists any Medicare coverage rules related to your case. The BFCC-QIO will usually call you to get your opinion.
You can also send a written statement. If you receive home health or CORF care, you must get a written statement from a physician who confirms that your care should continue. The BFCC-QIO should make a decision no later than two days after your care was set to end. Your provider cannot bill you before the BFCC-QIO makes its decision.
If you miss the deadline for an expedited BFCC-QIO review, you have up to 60 days to file a standard appeal with the BFCC-QIO. If you are still receiving care, the BFCC-QIO should make its decision as soon as possible after receiving your request. If you are no longer receiving care, the BFCC-QIO must make a decision within 30 days. If the BFCC-QIO appeal is successful, you should continue to receive Medicare-covered care, as long as your doctor continues to certify it.
In either situation, the focus is upon the medical necessity for the provided care. The patient’s medical provider should clearly explain this information to the individual receiving care.
We can help
If you find yourself overwhelmed by any Medicare issue, including continuing the care appeal process, feel free to contact the State of Alaska Medicare Information Office at 800-478-6065 or 907-269-3680. Our office is also known as the State Health Insurance Assistance Program (SHIP), the Senior Medicare Patrol (SMP), and the Medicare Improvements for Patients and Providers Act (MIPPA) program.
If you are part of an agency or organization that assists Seniors with medical resources, consider networking with the Medicare Information Office. Call us to inquire about our new Ambassador program.
Sean McPhilamy is a volunteer and Certified Medicare Counselor for the Alaska Medicare Information Office.
