If you feel you are being asked to leave the hospital (discharged) before you are well enough to go, you can ask for an immediate (expedited) independent review of your case. It is a good idea to ask a doctor for support (it is best to ask your treating physician, but you could always ask another doctor to lend support).
If you make a formal request for an immediate review within the proper timeframe, the hospital cannot force you to leave before a decision has been made. You should be able to stay in the hospital at no charge while your case is being reviewed. Even if it is decided that you do not need continued hospital care, the hospital cannot charge you for any care received until noon of the next calendar day after you get the review decision.
The first part of the process (what is described on this page) is the same whether you are in Original Medicare or a Medicare private health plan, like an HMO or PPO. Here’s what you need to do to request a review of your case:
1. Important Message from Medicare
When you are going to be discharged, you will get a copy of a notice called an Important Message from Medicare that describes your rights as a patient. This is the same document you should have been asked to sign within two days of being admitted to the hospital.
The notice will tell you how to request an immediate review of the hospital’s decision to discharge you (expedited determination) from the Quality Improvement Organization (QIO). A QIO is an independent group of doctors and other professionals that contracts with Medicare to ensure that you receive quality care (QIOs were formerly known as Peer Review Organizations).
The hospital must provide you with the copy of the Important Message from Medicare as soon as possible before your discharge date, but no more than two calendar days before and no less than four hours before you must leave the hospital. The second copy of the notice is not required if the first message is given within two calendar days of the discharge (if you are only in the hospital for three days).
Note: If you are not notified of your discharge and appeal rights, and you decide to stay in the hospital after your discharge date, you cannot be charged for the cost of your care.
2. Quality Improvement Organization (QIO)
To get an expedited review, you must contact the QIO by midnight on the date you are being discharged (and before you leave the hospital).
For the telephone number of the QIO in your state, click on the link in the LINKS box.
The QIO will inform the hospital of the appeal right away (that day or first thing the next morning if the request is received after the QIO is closed.)
To find out what happens if you file late for a QIO review, click on the links in the GO TO box that begin: "What can I do if I was asked to leave the hospital and I missed the deadline for asking for an immediate review of my case?"
3. Detailed Notice of Discharge
The hospital (or your plan if you are enrolled in a Medicare private health plan) must give you a Detailed Notice of Discharge no later than noon of the day after it is notified by the QIO that you are appealing the discharge. This notice must include an explanation of why services will no longer be covered, a description of Medicare coverage rules, and an explanation of how those rules apply to your case. It is important that you read this notice so that you are prepared when you have your QIO review.
The hospital or your plan must provide the QIO with the information it needs to decide your appeal by noon of the day after it is notified of the appeal. If you ask, the hospital must give you a copy of the information it gives the QIO by close of business the day after you request it (you may also want this information to prepare for your QIO review). The hospital or plan may charge a reasonable amount for duplication and/or messaging.
4. QIO Review
- continued hospital care is reasonable and necessary; or
- the needed care could be safely delivered in another setting, like a skilled nursing facility.
You (or your representative) must be available to discuss your case with the QIO (generally by phone). You have the option of submitting evidence in support of your case. You may want to ask a doctor to be present for the conversation with the QIO.
Based on the information gathered, the QIO will decide whether:
The QIO must contact you and the hospital by telephone and then in writing of its decision within one calendar day after it receives all information it has requested from you and the hospital.
If you disagree with the QIO’s decision, you can appeal at upper levels. The next levels of appeals are slightly different if you are in Original Medicare or a private health plan
To find out how to take your appeal to a higher level in Original Medicare or a Medicare private health plan, click on the links in the GO TO box that begin: “What can I do if I asked for a review of my hospital discharge and I lost?"