Discharge is the process of transferring (moving) from a hospital to another place and/or another level of medical care.
What can occur when the hospital wants to discharge a patient:
When discharge finally happens, all these things should be ready:
1. Insurance coverage arrangements - Always understand how much the insurance will pay.
2. Additional financial arrangements - Most insurance, including Original Medicare, won’t pay for 100% of costs at the post-discharge facility. How much you’ll pay will depend on the main insurance policy and any additional medical policies, such as a Medicare Supplement policy (also known as Medigap coverage).
3. Availability of appropriate caregivers - If the discharge is to home, decide which friends or relatives are available to provide care. Also consider the availability of professional caregivers (like nurses or physical therapists). If the discharge is to a facility, they’ll usually make arrangements for needed caregivers.
4. Medical supplies and equipment – Be sure these items will be delivered on time if your senior is discharged home. Facilities will usually arrange for needed medical supplies or equipment.
5. Room and board availability (other than at home) - Facilities in your desired location may not have space available when your loved one is ready for discharge. That’s why it’s essential to confirm that a bed has been reserved at a local facility you approve of.
6. Access to essential continuing medical care – For discharges to home, ensure that all follow-up appointments are already scheduled. This includes all doctor visits and other healthcare-related visits. If the discharge is to a facility, verify the facility has access to all the necessary health care professionals.
In reality, things can go awry when a patient is being discharged (see the above list of six items). If you believe your loved one is being released from a hospital too soon, you need to know what to do. This article offers suggestions on handling this situation if your loved one is covered by Original Medicare.
1. Original Medicare is also sometimes called “fee-for-service” Medicare or “traditional” Medicare.
2. Many of the same concepts and procedures for disputing or appealing hospital discharges apply for most other insurance (including Medicare Advantage), but details of the process will vary.
Many factors are taken into account when the decision is made to release a patient from the hospital, and multiple people in different roles are involved:
1. The treating doctors decide if the patient is medically stable for discharge.
2. Hospital discharge planners follow a patient’s course throughout a hospital stay to determine when a patient can safely be released. Discharge planners are usually nurses or social workers. Discharge planners consider medical status, availability of other care facilities, and insurance coverage when recommending discharge.
3. When recommending discharge, social workers consider psychological status, availability of social and family/friend supports, room and board options, and finances.
4. The medical insurance company (Medicare, Medicaid, or private insurance) follows the patient’s status while in the hospital. The insurance company uses specific medical criteria to determine when a patient should be discharged. The insurance company has the right to stop paying the hospital and doctors for all care once the insurance company deems the patient ready for discharge.
Sometimes it’s wise to accept and prepare for a hospital discharge decision. This is especially true when your loved one is medically stable, and all other issues are in order. Remaining in a hospital longer than is necessary can result in bad outcomes for multiple reasons such as:
1. Contracting a severe infection from staying too long in the hospital.
2. Ongoing exposure to potentially unnecessary services and procedures that lead to complications.
3. Medical errors – Every year at hospitals, many errors in care occur that lead to illness, disability, or even death.
Also, you should consider costs. Even if you dispute or appeal a discharge and win, you still may incur expenses for the additional days. This is because Original Medicare does not pay for 100% of hospital costs. As a result, you might have to pay part of the cost depending on which Medicare supplement insurance your loved one has (if any).
There are a number of reasons you might arrive at this conclusion:
1. The doctors have advised you they don’t think your loved one is medically ready for discharge.
2. Another healthcare professional has advised you they believe discharge is happening too soon. This could include a social worker, nurse, or physical/occupational therapist.
3. Your personal knowledge of your loved one – you know them best. You know what they can and cannot tolerate, and how they are doing compared to their baseline level of functioning. You will often have a sense of whether they are well enough to be discharged. Or, you might know of other issues that make postponing the discharge a good idea.
4. Financial and insurance issues – Insurance coverage (payment) arrangements might not yet be firmly in place. There might not yet be maximal insurance coverage arranged for medical care or room and board for wherever your loved one is going after discharge.
5. Caregiver issues - these usually arise when a patient is being discharged home. The hospital may expect you or another friend/family member to provide supervision and care for your senior at home, but this might not be doable for a variety of reasons:
6. Medical supply or equipment issues – these usually arise if a patient is being discharged home, when the supplies or equipment won’t or can’t be available or delivered to the home in time. Examples include:
7. Follow-up appointments with essential healthcare professionals, such as appropriate specialists, have not yet been made
8. Discharge to a skilled nursing or rehabilitation facility – Medicare won’t pay for care at these facilities upon hospital discharge unless a patient has been in the hospital for three days. So, if your loved one is discharged to these types of facilities sooner, you may have to pay the full price, which is very expensive. Be aware that Original Medicare has special rules as to how the days are counted. So, be sure you understand which days count toward the needed three days; a social worker or discharge planner should be able to explain this to you.
1. Talk with the doctors who are caring for your senior. If they agree with you, see if they can intervene.
2. Discuss your concerns with the social worker or discharge planner. There might be an issue they weren’t aware of that will postpone the discharge date.
3. Discuss your concerns with the hospital administrator to see if they agree with you and will intervene. Hospitals need to have patients staying there to make a profit. Also, Original Medicare can apply financial penalties when hospitals discharge patients too soon. As a result, the hospital has some incentive to keep your loved one there, so the hospital administrator might help you postpone the discharge.
4. “Safe Discharge” – Hospitals are required to follow Medicare rules for safe discharge. This means it must be safe (from medical, social, availability of care, and other perspectives) for the patient to go where the hospital intends to release them to. If you believe the planned discharge is unsafe, incorporate this issue into your discussions with the above people.
5. If the above steps fail or if you wish to bypass any of the above steps, you can file an Original Medicare discharge appeal.
A Medicare hospital discharge appeal is known as a “fast dispute.” File the Original Medicare discharge appeal as follows:
1. Within two days of hospital admission and before being discharged, you should be given a notice titled “An Important Message from Medicare about Your Rights.” This notice will tell you how to contact your Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO). The BFCC-QIO can assist you in filing a discharge appeal, and they will be the ones who decide (grant or deny) your appeal.
2. The hospital must give you a notice before discharge that explains how to file an appeal. Follow these instructions to file an appeal, and if you wish, request the BFCC-QIO to assist you in the appeal filing process.
3. You must file the appeal no later than the day of the scheduled discharge.
4. Different rules and procedures will apply if you are enrolled in Medicare Part C/Medicare Advantage. If you want to file a discharge appeal, you’ll usually need to ask your Medicare Advantage plan how to proceed.
After you file an appeal, the Original Medicare appeal process works as follows:
1. The BFCC-QIO notifies your Medicare plan and the hospital of your appeal.
2. Medicare or the hospital will give you a “Detailed Notice of Discharge” document explaining why Medicare and the hospital have determined your loved one should be discharged.
3. The BFCC-QIO will ask for your opinion. You can provide the BFCC-QIO with the reasons why you feel the discharge should be delayed. You’ll likely want to include comments about why the hospital is not providing a “safe discharge” (see above discussion of this term).
4. Within one day of receiving all information, the BFCC-QIO will notify you of its decision.
The BFCC-QIO will either approve or deny your appeal.
Stephen Engle is a United States-trained physician (M.D.) and Diplomate of the American Board of Internal Medicine who is board-certified in internal medicine. He has experience as a medical director in administrative medicine with the largest private payer in the US, as well as experience in internal medicine at all levels (clinic, urgent care, emergency room, inpatient general and intensive care, clinical consultative medicine, and peer review.)
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