Medicare and Hospital Discharges
Authored By: Northwest Justice Project
If you are a Medicare beneficiary, this publication explains your rights and processes when the hospital decides it is time to discharge you. Publication #5212EN
- When should I read my Medicare discharge notice?
- What are some terms I need to know?
- The hospital wants to discharge me. I disagree. What are my rights?
- When is the Medicare Hospital Discharge Notice (IM) Delivered?
- How many times do I get the IM?
- Are there any exceptions to this?
- What if I disagree with the discharge decision?
- What is a fast appeal?
- Does the hospital get to respond to my appeal?
- Will my Medicare Advantage plan send me anything at this point?
- How long does a fast appeal take?
- Who pays for the hospital stay during the immediate review?
- What if I disagree with the QIO’s decision?
- Get Legal Help
When should I read my Medicare discharge notice?
If you have Medicare and are in the hospital. It explains your appeal rights when the hospital decides to discharge you and you don’t agree with their decision.
What are some terms I need to know?
IM – An Important Message from Medicare. The hospital gives you this notice when it is going to discharge you. It explains your rights as a patient whether you are in Original Medicare or in a Medicare Advantage Plan. It also tells you how to ask for an expedited (fast) review of the discharge decision by the Quality Improvement Organization (QIO). You should have been asked to sign this notice within two days of being admitted to the hospital.
Hospital discharge –A hospital takes this action when the hospital believes you no longer need medically necessary services in the hospital and can be safely discharged. It may mean moving home with or without services, to a rehabilitation or nursing facility, or to supported housing like assisted living.
DND - Detailed Notice of Discharge. This Notice tells you your rights after you have asked for an appeal of the hospital’s decision to discharge you. It explains the reasons for the discharge.
Kepro – This is the Quality Improvement Organization (QIO) for Washington. It is responsible for handling hospital discharge appeals. It is a group of health quality experts, clinicians, and consumers organized to improve the quality of care delivered to people with Medicare, and to handle hospital discharge appeals.
IDN - Integrated Denial Notice. A Medicare Advantage health plan sends a Notice of Denial of Medical Coverage or Payment to inform you of any your appeal rights you may have when it denies you coverage of items and services, and when it will stop giving you or give you less of a previously authorized course of treatment, including hospital discharges.
The hospital wants to discharge me. I disagree. What are my rights?
The IM explains your rights. They include:
Receiving Medicare-covered, medically necessary hospital services and services you may need after you are discharged.
Being involved in any decision about your hospital stay.
Taking part in discharge planning, especially if you need rehabilitation services, nursing home placement, or home health services after you are discharged.
Making sure you and your doctors agree you are well enough to leave the hospital.
Asking for a fast appeal if you do not agree with the hospital’s decision to discharge you.
When is the Medicare Hospital Discharge Notice (IM) Delivered?
Hospitals must issue you An Important Message from Medicare (IM) within 2 days of admission and get your signature or your representative’s signature. Hospitals must also deliver a copy of the signed notice to you not more than 2 days before the day of discharge.
A hospital that believes you do not have the capacity to receive and understand the IM must deliver 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.
How many times do I get the IM?
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.
Are there any exceptions to this?
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 received 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 fewer than 48 hours before a scheduled discharge must give you the second notice at least four hours before discharge. Examples: The hospital bases your discharge on lab test results or the availability of a nursing home bed.
What if I disagree with the discharge decision?
You can appeal. Call Kepro Toll-free at 888-305-6759; TTY: 855-843-4776 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.
What is a fast appeal?
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.
Does the hospital get to respond to my appeal?
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. The DND must say:
Why you no longer need hospitalization or why it is no longer covered.
The Medicare rules and/or policies applying to your medical condition that led the hospital to decide to discharge you.
Will my Medicare Advantage plan send me anything at this point?
Yes. It will send you an Integrated Denial Notice (IDN). People also call it 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.
How long does a fast appeal take?
Kepro must make its decision within one calendar day after it gets all requested pertinent information, 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 assumes the hospital sent the records timely.)
Who pays for the hospital stay during the immediate review?
If you ask Kepro for an immediate review before midnight of the scheduled discharge date, you do not have to pay for the 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.
What if I disagree with the QIO’s decision?
You can appeal by calling Kepro and asking for a reconsideration.
Get Legal Help
Visit Northwest Justice Project to find out how to get legal help.