Sunday, July 5, 2015

Don't Risk Premature Hospital Discharge: Appeal

You've been in the hospital for three midnights, or more, as an Inpatient not an Outpatient, but you don't agree when your doctor says you're ready for discharge. It just doesn't 'feel right.' You're afraid. You don't want to land back in the hospital for the same ailment. You'd like a second opinion.
What can you do other than stay ~ and pay?
If you're an original Medicare beneficiary, appeal your discharge. Details and instructions are on the Important Message from Medicare (IM), given to you by the hospital when you arrived. You signed it, along with a batch of other admittance documents.
Lost the IM? Ask for a copy.*
If you suspect premature discharge, as soon as you learn of your impending discharge act quickly.
Protect yourself from a potential premature discharge by calling the Quality Improvement Organization (QIO) number on the IM.*
Called 'fast' or 'expedited' appeal, your phone call will start the process of a review made by a QIO. An 'expedited' appeal gets you a second opinion and buys time, without cost to you.
A QIO is under contract with the government: your medical records are examined by a physician, independent of the hospital, to review the medical necessity, appropriateness, and the quality of hospital treatment. The appeal is completed quickly and renders a final decision. The appeal also lets you stay in the hospital until noon (at least) of the day following your discharge date, and Medicare benefits apply during the time of the appeal process.***
You start the process by phoning QIO, and it should be completed in no longer than seventy-two hours, but you must call QIO before midnight on your discharge orders date.
  • Upon receiving an appeal request from the beneficiary, the QIO must notify the hospital immediately of the review request.
  • The hospital must provide patient records to the QIO by noon on the day after the QIO initially alerts the hospital to the expedited review request.
Note - there are reasons QIO may not alert the hospital for a considerable length of time, and also reasons why the hospital transmittal of records may not be complete for a considerable length of time - as long as seventy-two hour delays are possible.
Once the QIO notifies the hospital, the hospital is required to give a Detailed Notice of Discharge to the beneficiary (you) and to the QIO by noon the day after it is first notified of the appeal.
The Detailed Notice states the hospitals detailed rationale for the discharge. The QIO must receive a copy of the Detailed Notice in order to make a determination. The Detailed Notice also includes hospital contact information for the beneficiary.****
If you do not receive the Detailed Notice by noon the day after you contact the QIO with an appeal request, act quickly. Report this to the QIO so that the QIO can take action to facilitate delivery of the notice to you. You'll know your appeal is going as scheduled when you receive it.
The QIO must make its determination and notify the beneficiary, hospital, and physician within one calendar day of receipt of all pertinent information (delays can occur until records are complete.)
The hospital is prohibited from discharging you during your appeal, however if you leave the hospital before the review is complete, you abort your appeal.
If the QIO agrees that discharge is appropriate, you can agree to the discharge or you can file a reconsideration request for an independent review entity to review the case. If you stay in the hospital following receipt of a QIO decision that the doctor’s discharge orders are appropriate, you should receive a HINN12 from the hospital, because unlike the initial expedited review, there are no financial protections during the reconsideration process.
  • *Medicare, Medicare Advantage, and Medicaid each provide a hospital discharge appeals process.
  • ** If the beneficiary wishes to appoint a representative to file an appeal on his/her behalf, a valid Form 1696 or a conforming written instrument must be signed by both the beneficiary and the prospective representative and filed with the appeal request. In such cases the hospital has very specific obligations regarding notifications to the representative.)
  • ***Medicare does not cover inpatient hospital services that are not medically necessary or could be safely furnished in another setting. (Refer to 42 Code of Federal Regulations, 411.15 (g) and (k)). Options also remain to appeal an adverse decision.
  • ****Detailed Notice, Form CMS-10066,

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