Can I Appeal a Hospital Discharge?

Introduction

You've just been told that you or your loved one will be discharged from the hospital.

But you don't think the patient is ready.

Maybe your mother still seems weak and confused. Maybe your husband cannot safely get out of bed without help. Maybe the services you expected after discharge have not been arranged. Or perhaps you simply do not understand how the patient's needs will be managed after leaving the hospital.

Families in this situation often ask the same question:

"Can I appeal the hospital's decision to discharge?"

In some situations, yes.

Medicare beneficiaries who have been formally admitted to the hospital with inpatient status have specific rights to appeal when they believe they are being discharged too soon. If you are receiving hospital care under observation status, different Medicare rules apply. Being physically in a hospital bed does not necessarily mean that you have inpatient status. If you want to learn more about the difference between observation status and inpatient status, see Article 4, "Observation Status Explained."

The purpose of the appeal process is to allow an independent review of whether the patient's inpatient status hospital care should end. In practice, some patients and families also use the appeal process to gain additional time to make discharge arrangements. However, an appeal does not guarantee that Original Medicare will agree that continued hospitalization is medically necessary.

This article focuses specifically on the hospital discharge appeal process for people with Original Medicare. Medicare Advantage beneficiaries also have discharge appeal rights, but their insurance plan is involved in the process. If you have Medicare Advantage, follow the instructions provided by the hospital and contact your insurance plan with questions about the appeal process.

Understanding how the Original Medicare appeal process works—and acting within the required deadlines—can help patients and families make informed decisions during an already stressful time.

The Short Answer

If you have Original Medicare and have been admitted to the hospital with inpatient status, you have the right to request an appeal of the decision to discharge you.

The appeal is reviewed by an independent organization that contracts with Medicare through the Beneficiary and Family Centered Care-Quality Improvement Organization program. In hospitals, these organizations are usually referred to simply as Quality Improvement Organizations, or QIOs.

The QIO—not the hospital—reviews whether the patient's hospital care under inpatient status is still medically necessary under Medicare's requirements.

The phone number for the QIO and instructions for requesting an appeal are provided on a document called the Important Message from Medicare, often called the IM or IM letter. We'll explain the IM letter in more detail in Section D.

The deadlines are short. If you are considering an appeal, it is important to act promptly.

First, Understand What Is Being Appealed

One of the most important distinctions is between disagreeing with the discharge plan and appealing the decision to end hospital care under inpatient status.

They are related, but they are not exactly the same thing.

You may believe that going home is unsafe because no caregiver is available, the patient cannot manage stairs, necessary medical equipment has not arrived, or home services have not been arranged.

Those concerns are important and should be discussed with the healthcare team.

But the central question in an Original Medicare hospital discharge appeal is whether the patient still requires hospital care under inpatient status.

An appeal does not necessarily determine where the patient should go after hospitalization, whether a preferred skilled nursing facility will accept the patient, whether family members are able to provide care, or whether every part of the discharge plan is ideal.

The QIO is reviewing the decision that the patient's hospital care under inpatient status should end.

Understanding that distinction can help you decide whether the problem involves the decision to end hospitalization, the discharge plan itself, or both.

What Is the Important Message from Medicare?

Medicare beneficiaries admitted to the hospital with inpatient status should receive a written notice called "An Important Message from Medicare about Your Rights," commonly called the Important Message from Medicare, the IM, or the IM letter.

The IM explains several important rights, including the right to receive medically necessary hospital care, participate in decisions about your care, receive information about services you may need after discharge, and appeal a hospital discharge decision.

The hospital must provide the initial IM at or near the time of admission. Medicare rules allow the hospital to provide it as late as two calendar days after admission.

You or your representative are asked to sign and date the notice to acknowledge that you received and understood it. Signing the IM does not waive your right to appeal later in the hospitalization.

Signing the IM does not mean that you agree with a future decision to discharge you.

Many hospitals use tablets or other electronic systems to obtain signatures. When your signature is obtained electronically, the hospital must still provide you with a copy of the IM letter for your records.

If the initial IM was provided more than two calendar days before the planned discharge, the hospital must provide a follow-up copy.

The follow-up IM must be provided as far in advance of discharge as possible, but no more than two calendar days before discharge. If it must be provided on the day of discharge, the hospital must give you at least four hours to consider whether you want to appeal.

If the initial IM was provided within two calendar days of discharge, Medicare does not require a separate follow-up copy.

If you are considering an appeal and cannot find your IM, ask the hospital for another copy. The QIO phone number and instructions for requesting an appeal are on the notice. For official instructions about fast appeals, visit Medicare's fast appeals page.

How Do I Start an Appeal?

Starting an Original Medicare hospital discharge appeal is relatively simple.

Call the QIO listed on your Important Message from Medicare and tell them:

"I want to appeal my discharge."

You do not need to prepare a medical argument before making the call.

You do not need to prove that the hospital is wrong before requesting the appeal.

The QIO may ask why you disagree with the discharge and may ask questions about your concerns, but requesting the appeal starts the review process.

Under Medicare rules, the hospital needs to show that the decision to end the patient's hospital care under inpatient status is appropriate based on medical necessity or other Medicare coverage requirements.

To receive the financial protections associated with a timely appeal, contact the QIO no later than the day you are scheduled to be discharged.

Do not wait until after leaving the hospital if you already know that you want to appeal.

What Happens After I Appeal?

Once the QIO receives your appeal, it notifies the hospital that the discharge decision is being reviewed.

The hospital must send the QIO the medical records and other information needed to support its decision.

The hospital must also provide you with another document called the Detailed Notice of Discharge, or DND.

The DND explains why the hospital believes your hospital care under inpatient status should end and identifies the Medicare rules or policies supporting that decision.

The QIO reviews the hospital's information and also considers your perspective.

You or your representative may explain your concerns to the QIO and provide additional information if you choose.

The QIO must make its decision within one calendar day after it receives the information needed to complete the review.

Because the process moves quickly, you or your representative should remain available in case the QIO needs to speak with you.

Who Pays While the Appeal Is Being Reviewed?

This is one of the most important parts of the appeal process.

If you appeal on time, Original Medicare continues to cover your hospital care under inpatient status while the QIO completes its review. Normal Medicare deductibles and coinsurance still apply.

If the QIO decides that continued hospital care under inpatient status is medically necessary, Original Medicare coverage continues as long as Medicare's coverage requirements are met.

If the QIO agrees with the hospital that your hospital care under inpatient status should end, your Medicare coverage does not end immediately when you receive the decision.

While the appeal is in process, Original Medicare continues to cover your hospital care under inpatient status. If the QIO agrees with the discharge, this financial protection continues through noon of the calendar day after the QIO notifies you of its decision.

For example, if the QIO tells you Tuesday afternoon that it agrees with the hospital's discharge decision, Original Medicare coverage continues through noon on Wednesday.

The QIO's decision should explain when Medicare coverage ends and when you could become financially responsible if you choose to remain in the hospital.

What If My Main Concern Is That Going Home Is Unsafe?

This is where discharge disagreements can become complicated.

A patient can be medically ready to leave the hospital and still need substantial help after discharge.

Those are two different issues.

Someone may no longer require hospital care under inpatient status but still need assistance with walking, bathing, dressing, medications, wound care, oxygen, toileting, meals, or other daily needs.

If your primary concern is what will happen after the patient leaves the hospital, talk with the hospital case manager and healthcare team.

Be specific about the problem.

Instead of saying:

"My mother isn't ready."

Consider saying:

• "No one will be home with her during the day."
• "She cannot get to the bathroom without assistance."
• "There are stairs she cannot climb."
• "The medical equipment has not arrived."
• "We were told home health would be arranged, but we do not know whether anyone is actually coming."
• "I do not understand how her care needs will be met at home."

Specific concerns are easier for the healthcare team to address.

Sometimes the issue is not whether the patient needs to remain hospitalized. The issue is whether the discharge plan adequately addresses what the patient will need after leaving.

Common Misconceptions

"If I appeal, the hospital has to keep me."

Not indefinitely.

A timely appeal allows the QIO to independently review whether the patient's hospital care under inpatient status should continue and provides financial protection while that review occurs.

The QIO may agree with the hospital that continued hospitalization is no longer medically necessary.

"I need to prove that the hospital is wrong before I call the QIO."

No.

You can simply call the QIO and request an appeal.

The hospital needs to support its decision that your hospital care under inpatient status should end.

"If my mother still needs help walking, Medicare has to keep paying for the hospital."

Not necessarily.

Needing help with walking or other daily activities does not by itself mean that hospital care under inpatient status remains medically necessary.

The question is whether the patient still requires the level of medical care that needs to be provided in the hospital.

"If the discharge plan isn't perfect, I should appeal."

Not necessarily.

First identify what you are actually concerned about.

Some concerns involve whether hospitalization should continue. Others involve what services, equipment, caregiving, or other arrangements are needed after discharge.

Sometimes both issues need attention.

Questions to Ask If You Are Considering an Appeal

If you disagree with a hospital discharge, consider asking:

• Am I currently admitted with inpatient status?
• Why does the doctor believe I am medically ready to leave the hospital?
• What medical needs will I still have after discharge?
• Where and how will those needs be met?
• What services or equipment have actually been arranged?
• Can I have a copy of my Important Message from Medicare?
• What is the phone number for the QIO?
• What is my deadline for requesting an appeal?
• If the QIO agrees with the discharge, when will Original Medicare coverage of my continued hospital stay end?

Write down the answers.

Hospitalizations move quickly, and discharge appeals move even faster.

Knowing the deadlines and understanding what decision is actually being reviewed can help you make better decisions under pressure.

How HNav Can Help

Hospital discharge decisions can move quickly while patients and families are trying to understand medical recommendations, Medicare rules, care options, and what will happen next.

HNav helps patients and families understand the discharge process, identify the questions they should be asking, and make sense of the choices available to them.

Our goal is not to make decisions for you or tell you whether you should appeal.

Our goal is to help you understand what is happening so that you can participate more effectively in decisions about your care or the care of someone you love.