Many of us know someone who has been told that they are being discharged from a hospital or rehabilitation facility when they do not feel they are ready. I recently saw a friend go through this when her husband was advised he would be going home. But they believed he was still improving and would benefit from more time and care at the facility. What if any recourse do we have if this should happen to us or a friend or family member?
Our recourse in California is through Livanta which is a Beneficiary and Family Centered Care Quality Improvement Organization (BFF-QIO). BFCC-QIOs are responsible for medical case review, which supports the rights of people on Medicare (there are other Livanta type organizations around the country). These rights include protecting you when you are getting health care and making sure you get the health care services for which you are eligible. BFCC-QIOs can help you if you have a concern about the care you have been receiving or if you want to request a review (appeal) of your discharge from a health care facility.
These services for beneficiaries and family services include: Appeal of Discharge, Quality of Care Concern (immediate) and Beneficiary Complaint. Livanta provides a list of resources if concerns fall outside the purview of Livanta on their website listed below.
What is an appeal of discharge from a facility? An appeal can occur if you think your Medicare services are ending too soon. If you are in a medical facility and are advised that you are going to be discharged, but still feel too sick to leave or feel you need more improvement, you can appeal your discharge through Livanta.
When you are going to be discharged, you will be given a notice in writing called “An Important Message from Medicare.” This notice explains how you can appeal your discharge. To file an appeal, you will need to contact Livanta’s HelpLine at 877 588-1123 or 855 887-6668 TTY. Their hours of operation are Monday-Friday: 9:00 am – 5:00 pm and Saturday-Sunday: 11:00 am – 3:00 pm (local times).
How will the process proceed after an appeal is filed? Once Livanta receives the phone call to start the appeal, the clock stops on the discharge and they will contact your health care provider to request your medical record. Once received it is sent to a physician reviewer who will study your record. The reviewer decides whether you are heathy enough to be discharged. You will then receive a phone call and letter from Livanta with their decision.
You can appoint a representative to speak on your behalf by using the Appointment of Representative form or by submitting your request in writing.
A major consideration for anyone considering appealing their pending discharge is who will pay for my hospital care, not including copays and deductions, after you notify Livanta in a timely manner and before their investigation is completed. When Medicare informs you that skilled services will be terminated, the Notice of Medicare Non-Coverage states that it possible that you may have to pay for the skilled services you receive after the effective ending date of skilled services.
When you file a timely appeal of your discharge, you are not required to pay for skilled care until the appeal is complete, which usually takes about 48 hours. A timely appeal is when you call Livanta by noon on the day before the effective date on the NOMNC (Notice of Medicare Non Coverage). A provider may not bill a beneficiary who has filed an appeal on time until the review process is complete.
If Livanta determines that you need to continue to stay in the hospital, Medicare will continue to pay for your care. If Livanta agrees that you are ready for discharge, you will be required to pay starting at noon of the day after the determination. If you appeal to Livanta, you cannot be discharged before the appeal is complete without your consent. You may or may not get additional days of coverage. When any additional coverage period is over and you get a second Notice of Medicare Non-Coverage, you can file another appeal.
What are the skilled care services that are covered by Medicare? Medicare Part A (Hospital Insurance) covers skilled nursing services in a skilled nursing facility (SNF) under certain conditions for a limited period of time. These services include a semi-private room, meals, skilled nursing care, medications, medical supplies and equipment used in the facility, medical social services and dietary counseling. Ambulance transportation to the nearest supplier of necessary services not available at the SNF is covered. Physical and occupational therapy and speech pathology services are provided when they are needed to meet your health goals.
While I have been aware that it was possible to appeal discharge decisions, I did not realize how to begin the appeal process until watching my friend work through the system. When she learned that her husband’s Medicare coverage at the rehab facility would stop on Friday, she was told to contact Livanta before noon on that day. She made the call to Livanta at 9:00 am on that Friday and was told that they would be reviewing her husband’s medical records and would contact her with their decision. They notified her on Monday that his coverage would not be extended and he would need to leave the rehab facility by noon on Monday or they would be billed for any further time. While she did not get the additional week she had requested, her husband was able to continue rehab from Friday until Monday noon. Without the appeal, he would have been discharged on Friday. Having this option of extra time also gives caregivers the time to get prepared for the patient’s homecoming.
In my friend’s situation the case management staff at the facility was very helpful in explaining the appeal process and answering her questions. I recently attended a webinar on Elder Abuse and Skilled Nursing Facilities with an Agent from the CA Department of Justice and an Assistant District Attorney from Santa Cruz County. Based on their very disturbing presentations, it does not sound like every facility will be as helpful as our local rehab facility when a patient is being discharged. This post is just a brief summary of how the discharge appeal process works and is intended to bring awareness to the right you have to appeal discharges when you believe Medicare services are being terminated too quickly.
Full information can be found at livantaqio.com regarding discharges and other services provided by Livanta.
Thanks for this informative article. I did not know about this appeal process. I live in Washington State, which Livanta does not cover. So I googled BFCC-QIO and found Kepro, which seems to cover the nation. It describes itself as “the Medicare Quality Improvement Organization” — not sure if they offer the same services that Livanta does.
Very interesting. I attended a webinar last week on issues with some SNF’s and one of them was that they do not always notify people in a timely manner that they or their loved one is going to be discharged until the last minute. Then they sometimes use scare tactics to “encourage” getting the patient out very quickly before proper arrangements have been made for the patient’s safe return home. It is up to us to make sure our rights are protected. Thanks, Fran
Very significant information to pass on to our friends. A wonderful article. Thank you
Thanks, Barbara. It is so critical now that we know our rights and how to protect them.
Good to know! I did not know about this appeal process.
My friend was in one of our local rehab facilities and they did everything to make sure that she knew about the process and how and when to file her appeal. I was very positively impressed by them but I know that is not the case with some facilities. Thanks, BK.