Medicare and Hospital Discharges

Yes, you should read this if you have Medicare. If you must stay at the hospital for more than one night (if you get inpatient treatment), you should know what your rights are if you and the hospital disagree when you should go home. 

If you have Medicare and the hospital admits you for inpatient treatment, then you should receive an Important Message from Medicare (also called an IM) within 2 calendar days of admission. We've attached a sample IM below.

The IM explains your patient rights. These include your rights when you are released from the hospital (when you are discharged).

The hospital will ask you or your representative to sign the IM to confirm you got it and understand your rights.

You can refuse to sign it. The hospital may insist you sign it. The hospital asks you to sign to show that it told you (notified you) of your rights as a patient.

If you refuse to sign, the hospital might instead note your refusal on the form and the date. It will note the date of your refusal as the date it told you of your rights as an inpatient hospital patient.

Refusing to sign should not change your right to a fast decision on your appeal (called an expedited determination on appeal).

The rest of this fact sheet will focus on your patient rights regarding discharge.

Hospital discharge –A hospital takes this action when it believes you no longer need medically necessary services in the hospital and can safely be released from the hospital. This could mean moving home with or without services, to a rehabilitation or nursing facility, or to supported housing like assisted living.

IM – An Important Message from Medicare. The hospital gives you this notice within 2 days of admission to hospital and again within 2 days of discharge. This is true for both Original Medicare and Medicare Advantage Plans. The IM explains your rights as a patient. It also tells you how to ask for an expedited review of the discharge decision by the Quality Improvement Organization (QIO; see below). You should have been asked to sign this notice within 2 days of being admitted to the hospital.

Kepro – This is the Quality Improvement Organization (QIO) for Washington. Kepro processes hospital discharge appeals.

DND – Detailed Notice of Discharge. This notice tells you your rights after you have asked to appeal the hospital's decision to discharge you. It also explains the reasons for the discharge.

IDN - Integrated Denial Notice. If you have Medicare Advantage, your health plan will send you this notice to tell you about any appeal rights you may have when it turns you down for (when it denies you) coverage of items and services, and when it will stop giving you, or will give you less of, a previously authorized course of treatment, including hospital discharges.

• You can disagree and appeal as we explain below, or

• You can ask for a discharge planning evaluation if you think you could be ready for discharge with planning and support

It is when hospital staff work with the patient, or patent's representative, to develop a way for you to leave the hospital safely.

This could mean various things. It could simply mean healing at the hospital from a procedure. It might mean you should be discharged to hospice or a home health services. It might mean ensuring you understand how to clean your surgery site.

The IM explains your rights. They include:

• The right to get Medicare-covered, medically necessary hospital services and services you may need after your discharge.

• The right to be involved in any decision about your hospital stay.

• The right to take part in discharge planning, especially if you need rehabilitation services, nursing home placement, or home health services after your discharge.

• The right to make sure you and your doctors agree you are well enough to leave the hospital.

• The right to ask for a fast appeal if you do not agree with the hospital's decision to discharge you.

If the hospital wants to discharge you more than 2 days after admission, you should get another IM notice. This is the same notice they asked you to sign upon admission.   

A hospital that believes you do not have the capacity to receive and understand the IM must give it to and get a signature from an appropriate representative. If a representative is not readily available in-person, the hospital can give notice by phone and then mail the written notice. Answering machine or voicemail messages are not okay.

You must get it twice while hospitalized:

• The hospital must deliver the first IM no later than 2 days after admitting you.

• You must get the second IM 2 days before the planned discharge day.

Yes:

• If the discharge date is within 2 days of signing the initial (first) IM. You may be in the hospital fewer than 5 days. Example: The hospital admitted Sophia on Sunday. She got and signed the IM on Tuesday. The hospital has Sophia's discharge scheduled for Thursday. The hospital does not need to give her a second copy of the notice.

• If the discharge decision happens quickly. A hospital that reaches a decision less than 48 hours before a scheduled discharge must give you the second notice at least 4 hours before discharge. Examples: The hospital bases your discharge on lab test results or the availability of a nursing home bed.

*You have the same appeal rights if you get notice on the day of the discharge.

You can appeal. Call Kepro toll-free at 888-305-6759; TTY: 7-1-1 before the end of the discharge date to appeal. You can call 24 hours a day, including weekends.

We call this a fast appeal, expedited decision, or immediate review. 

If you missed your appeal deadline, the IM you received tells you whom to call.

When Kepro gets a fast appeal request, it

• Notifies the hospital you have started an appeal.

• Asks the hospital for records.

The hospital must give Kepro the records to review and decide if the medical facts and Medicare rules support the discharge decision.

You, or your representative, can ask the hospital to give you a copy of the documentation it sent to Kepro. The hospital must do this when you ask. It can charge you a reasonable amount for copies. To avoid potential costs, you could ask to just have access to the documents.

The hospital has until close of business the first day after your request to give you the records.

Yes. The hospital must give you a Detailed Notice of Discharge (DND) by noon of the day after it gets notice of the fast appeal. We've included a sample form below.

The DND must say:

• Why you no longer need hospitalization or why it is no longer covered.

• The Medicare rules and/or policies that led the hospital to decide to discharge you.

Yes. It will send you an Integrated Denial Notice (IDN). This is also called a Notice of Denial of Medical Coverage/Payment. The IDN must say:

• Why the hospitalization (or other service) is no longer covered.

• Your appeal rights. This includes how to ask for an appeal.

The IDN should also have:

• Plan contact information.

• Medicaid appeals rights information for people who get Medicaid services.

Kepro must make its decision within one calendar day after it gets all the information it asked the hospital for, including hospital records.

If you appealed the decision before midnight on the day of the scheduled discharge, the fast appeal should take no more than 2 days.

Example: Joe is a Medicare patient. They tell him the discharge date is Thursday. Joe calls Kepro Thursday afternoon. By Friday, the hospital should

• Give Joe a DND.

• Send Kepro his records.

On Saturday, Kepro should reach its expedited decision and tell Joe and the hospital its decision. (This may not be the case if the hospital did not send the records timely.)

If you ask Kepro for an immediate review before midnight of the scheduled discharge date, you do not have to pay for your continued hospital stay, even if Kepro rules against you. You are liableif you stay in the hospital after noon of the day Kepro tells you it is upholding the discharge date.

In the example in the last section, Joe would be liable for the cost of the hospital stay if he stayed in the hospital past noon on Saturday.

You can appeal by calling Kepro and asking for a reconsideration.