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Medicare Hospital Discharge Notice Procedures and Benefits Counseling

In This Article:

• Why are Medicare Discharge Notices important to benefits counselors?
• What can a beneficiary who disagrees with the discharge decision do?
• What happens when Medicare patients request an immediate review?
• How long does the immediate review take?
• Who pays for the hospital stay during the immediate review process?
• What should Medicare Advantage Plan Members know?

Why Are Medicare Discharge Notices Important to Benefits Counselors?

Almost 14 percent of the 43 million Medicare beneficiaries are hospitalized every year so it is very likely that you encounter beneficiaries who have or will experience a hospital stay this year. Most of these hospitalizations are very short, with 43 percent lasting less than three days according to CMS data. A new notification procedure and newly designed notices will be implemented on Monday July 2, 2007.When Medicare beneficiaries to understand the hospital discharge notification system they are better equipped to:

• Participate in the discharge planning process, especially if they need nursing home placement or Medicare-covered home health services upon discharge;
• Make sure they and their treating physicians are in agreement that they are well enough to leave the hospital;
• Initiate an expedited Medicare appeal by requesting an Expedited Decision if they do not agree with the decision that they no longer need to be treated in the hospital; and
• Assure that they can obtain needed prescriptions? through their Part D plan after Medicare Part A stops paying for medications through the inpatient hospital benefit.

For all of these reasons, your help is a key to empowering Medicare beneficiaries to participate in decisions about their care. Thats why were updating you about the Medicare procedure for notifying Medicare-covered in-patients that their Medicare coverage for their hospitalization will soon end.

Hospital notices must be given to hospitalized Medicare beneficiaries.

Starting on Monday July 2, 2007, hospitalized Medicare beneficiaries must receive a written statement called the Important Message From Medicare About Your Rights (78Kb PDF file) not later than two days after they have been admitted as an in-patient. The Important Message explains their rights when the hospital decides they no longer need to remain in the hospital because they can go home and/or obtain medically needed care in another setting, such as a nursing home. Patients will be asked to sign the notice to indicate that they received it and that they understood it. If a hospital has reason to believe that specific Medicare patients lack the capacity to receive the Important Message and to understand its contents, hospitals must deliver the notice and obtain a signature from an appropriate representative of the beneficiary. CMS has stated that if the representative is not readily available in person, the hospital may give oral notice by telephone and then mail the notice. Messages left on answering machines or voicemail are not acceptable because there is no opportunity for the hospital to assess whether the representative has actually received and understood the notification.

Another copy of the notice may be given to the patient when the hospital determines the patient is ready for discharge.

As soon as hospitals reach discharge decisions, but never more than two days preceding the scheduled discharge date, the hospital must give Medicare patients another copy of the signed Important Message notice. A key exception to this rule is that if the discharge date is within two days of when the hospital delivered and obtained a signature on the initial copy of the Important Message delivery of a second copy is not required.

For example:
A patient who was admitted on Sunday received and signed the Important Message on Tuesday and is scheduled for discharge on Thursday need not be given a second copy of the notice. If, however, discharge was scheduled for Friday, the second notice would be required to be delivered on Wednesday.

Since most Medicare beneficiaries stay in the hospital for five days, it is likely that in most cases, patients will only receive one notice and will learn of the projected discharge date through oral communication with hospital staff.

Sometimes hospital discharge decisions are made very quickly, based, for example, upon the results of lab tests or the availability of a bed in a nursing home. When decisions are reached less than 48 hours prior to a scheduled discharge, the second notice must be delivered to the patient at least 4 hours prior to discharge. The same appeals rights remain applicable to a patient who receives notification on the day of the discharge.

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What can a beneficiary who disagrees with the discharge decision do?
Medicare patients who do not agree that they are ready for discharge may appeal the hospital decision by contacting the Quality Improvement Organization (QIO) by the end of the date set for the discharge. The Important Message explains how to appealby calling their QIO. Contact information is included within the notice and the QIO can be contacted to initiate the appeal at any time, 24 hours a day, including weekends.

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What happens when Medicare patients request an immediate review?
When the QIO receives a request for an Expedited Decision, it informs the hospital that an appeal has been initiated. The hospital must then give the patient another more detailed notice (46Kb Word file) of discharge in writing by noon of the following day. The detailed notice explains the specific Medicare coverage rules that led the hospital to reach its decision to discharge the Medicare patient. It also must contain specific information about the patients medical condition that led the hospital to conclude that under the Medicare coverage rules the patient was ready for discharge. Simultaneously, the hospital must transmit records requested by the QIO to review in order to reach a decision as to whether or not the medical facts and Medicare rules support affirming the discharge date.

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How long does the immediate review take?
The QIO must reach its decision one day after it receives the requested records from the hospital. The entire process by which the QIO reaches its expedited decision as to the appropriateness of the hospital discharge should take should not take more than two days as long as the patient made the request for the expedited decision before midnight on the day of the scheduled discharge.

For example:
If a Medicare patient is told the discharge date is Thursday and she calls the QIO Thursday afternoon, the hospital should give her a detailed notice and send her records to the QIO by Friday at noon. The QIOs expedited decision should be reached and communicated to the patient and the hospital on Saturday.

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Who pays for the hospital stay during the immediate review process?
Patients who ask the QIO promptlybefore midnight of the scheduled date of dischargefor an immediate review are not held liable for the cost of the continued hospital stay, even if the QIO rules against them, unless they remain in the hospital after 12:00 noon of the day after they are told by the QIO of a decision that affirms the discharge date.

For example:
In the example above, the patient would not be held liable for the cost of the hospital stay unless she stayed in the hospital past 12:00 noon on Sunday.

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What Medicare Advantage Plan Members should know
Medicare Advantage plans, rather than hospitals, make the decisions regarding hospital discharge for members. Members of Medicare Advantage plans are given their notices by the plan, not the hospital.

The Medicare Manual Change Request (388Kb PDF file) contains the new policy and procedures, which also describes the liability of Medicare patients who stay in the hospital after the scheduled discharge date.

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