A Discharge Dilemma: Successful Medicare Appeals are Rare

Here is a bit of information that you might find helpful if you are on Medicare and about to get inappropriately discharged from the hospital.

If you are on Medicare, then you can stay in the hospital only if there is a good medical reason.   When your doctor, or the hospitalist if your doctor is not overseeing your care during your hospital stay, decides that there is no longer a good medical reason for your stay, then he or she will issue orders that you should be discharged from the hospital.

If you disagree with the discharge, you can appeal the hospital’s discharge decision.

So how do you appeal?  You contact your BFCC-QIO, short for Beneficiary and Family Centered Care-Quality Improvement Organizations, which is the organization designated by the Centers for Medicare & Medicaid Services to handle discharge appeals.

To start the appeal process, you or your representative must call the BFCC-QIO no later than the day of the discharge and let it know that you need an “expedited determination”.  That buys you some additional Medicare coverage – you will be financially responsible only for your coinsurance and deductible until noon of the day after you receive the BFCC-QIO decision.

When you call, you or your representative must be available to discuss the case.  You may also submit written evidence to back your appeal.

The BFCC-IO then contacts the hospital, which is required to issue a detailed notice containing your case facts and the applicable Medicare coverage rule.  The burden is on the hospital, not you, to produce evidence to support the discharge.   However, the hospital does not have to produce your entire case record, so it will send only the documents that support the discharge decision.

You have the right to refute the hospital’s documents and the doctor’s opinion, but this is where reality clashes with theory.

You are sick and in the hospital bed.  That makes it almost impossible for you to gather your own records or obtain an expert to dispute the hospitalist’s opinion.  Your medical representative is often of limited help due to the short time period or lack of experience with the medical world.

One trick that may work is to contact your personal physician and find out if he or she will support a longer hospital stay.  If so, then ask your personal physician to either contact the hospitalist or to write a note that you can submit to the BFCC-QIO.

Back to the workings of the appeal – the BFCC-QIO has to issue its decision within one calendar day after it receives all requested pertinent information.

If you disagree with the decision and appeal further, then you will be financially responsible for your continued hospital stay if you do not win.  If you do proceed, then here are the appeal levels:  Qualified Independent Contractor, Administrative Law Judge, Medicare Appeals Council, Federal district court.

The takeaway?  A Medicare appeal may buy you 1 or 2 extra days, but the chances of winning are slim.

Virginia Hammerle, Managing Attorney for Hammerle Finley Law Firm, has been recognized from 2012-2018 as a Super Lawyer, a Thompson Reuters Publication.  See hammerle.com for her blog and newsletter sign-up.  This column does not constitute legal advice.