How Can You Appeal a Hospital or Nursing Care Facility’s Decision to Prematurely Release a Patient?

One of the dilemmas we face in our society today is the high costs of medical care. Unless you are amongst the wealthiest 5%, more than likely you have limited coverage purchased from the health insurance industry depending on what your premiums are; the higher your premium, the more thorough your coverage.

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Obviously those with lower premiums have high deductibles and less coverage and are subject to earlier discharges from medical facilities they’ve been admitted to because their insurance benefits cannot cover the medical expenses necessary to treat them completely. It is often the goal of medical administrative staff and insurance providers to have patients discharged whose high dollar care cuts into their profits.

Those most likely to find themselves facing early discharge are low-income patients like many seniors whose only means of medical insurance is through Medicare. Medicare pays a flat rate to hospitals based on what the procedure is. If that institution is able to provide the service at a rate below Medicare’s rate they make a profit; if not they take a loss. It is when these rates no longer sufficiently cover the costs of medical care or when insurance providers are unwilling to continue coverage that forces budget-focused administrations to pressure doctors and other medical staff to find reasons to discharge these patients earlier than their conditions necessitate.

Quality Improvement Organization contractors (QIOs) are hired by the Center for Medicaid and Medicare Services (CMS) to address such abuses. They are available free of charge to patients who feel their early discharges are based on monetary concerns rather than sound medical decisions. Such organizations, like the Health Services Advisory Group, Inc. serve their clientele “by providing quality expertise to those who deliver care and helpful information to those who receive health care services.” They are but one element in a Medicare peer review organization mandated by federal law that insures patients receive “quality, access, timeliness, and appropriateness of care” from the facility their doctor has admitted them to.

The Medicare patient, upon learning that they are being discharged before they feel they should, is required to state their views to hospital staff. If their protestations are ignored then the patient can appeal their decision and should contact a QIO authorized by CMS as soon as possible, giving them the details about their pending discharge. Under the law Medicare will continue to pay for hospital care until the issue is resolved one way or the other.

Once the patient files an appeal through a QIO the medical facility must present the patient with aDetailed Notice of Discharge to justify their actions. The hospital or care facility is also required to send the patient’s records to that QIO for review in helping them form an assessment. Usually within a day of receiving all of the pertinent information from the patient and care facility, the QIO will make a determination and transmit this information to all parties by phone and in writing.

If the QIO agrees with the patient then the hospital is obligated to continue its care for them and will continue to be paid by Medicare at the rate they originally accepted the patient at. If they rule in favor of the care facility then they will only continue covering a patient’s stay until noon of the day following their decision. Most states have laws set up to protect elderly patients, on Medicare or low-cost health insurance plans, from unreasonable discharges by licensed medical care-giving facilities. Each patient or their family should be familiar with their rights to appeal a decision for what they feel would be a premature discharge before or shortly after a hospital or nursing care facility admits them.

If a transfer from a nursing facility doesn’t pose a physical threat to a patient they are allowed to transfer patients for the following reasons only:

1. Medical care the resident requires cannot be provided in a nursing home setting.

2. The resident no longer needs nursing home care because the resident’s condition has improved.

3. The health or safety of other individuals in the home is endangered.

4. In the case of a self-pay patient, the resident has not paid for care at least fifteen days.

5. The home plans to cease operations. (SOURCE)

All appeals with patients, whether on Medicare or private coverage, must file their complaints within 10 days of being advised of their discharge (though exceptions up to 30 days can be made). Unless it is an emergency situation nursing facilities must give you or your guardian, “a written notice, at least 30 days, and no more than 60 days, before a transfer or discharge from one facility to another.” This written notice must contain information that provides the facilities reason for the discharge or transfer, dates, location to where patient will be moved, your legal rights and the details necessary to file an appeal, including the name, mailing address and telephone number of Long-term Care Ombudsman.Without these specifics it is unlawful to take action to discharge and relocate a patient from their originally assigned facility.

Patients and their families should contact the local offices of their state’s Public Health Department to assist them in protecting their rights as a patient. Half of all elder abuse cases reported are related to a failure to fulfill a care taking obligation. Health care fraud and abuse are often perpetrated by unethical doctors, nurses, hospital personnel, and other professional care providers. Knowing your rights on what constitutes a legitimate cause for being discharged or re-located to another care provider should be at the top of any one’s list that has a loved one subject to these conditions. Proper care should not be short-changed because profit-motivated facilities or insurance providers want to game the system to their advantage.

RESOURCES:

ElderCare Expert Bolg

Health Services Advisory Group

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3 responses to “How Can You Appeal a Hospital or Nursing Care Facility’s Decision to Prematurely Release a Patient?

  1. It is amazing that in the US, this is a problem. But then again, health care for every age group is a problem. It is sad that the elderly’s needs are shortchanged or a company’s profits, but then again that is the American way and that is how most,including the elderly, voted it to be. Excellent post as always. Your research is so thorough and accurate. Nice to see that in this day and age of copy and paste writers. LOL

  2. Thank you for wonderful information. I maintain a blog about insurance called TIB Tips. Each month I spotlight a different Health Care issue. The month of February the spotlight shines on the need for effective Long Term Care planning for those about to retire. What you have to say will fit in nicely. I will put a link to your blog in one of my articles.

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