How to File a Fast Medicare Appeal of a Hospital Discharge or Service Denial

If you believe your Medicare-covered health care services are ending too soon or you're being discharged from a hospital or skilled nursing facility prematurely, you have the right to request an expedited, or "fast," appeal. That allows you to fast-track challenges to decisions about Medicare-covered services from a:

• hospital
• skilled nursing facility (SNF)
• comprehensive outpatient rehabilitation facility (CORF)
• home health care agency (HHA), or
• hospice agency.

Understanding Medicare's process for fast appeals can help you ensure you receive the care you deserve and that Medicare pays for it.

Appealing a Hospital Discharge or Denial of Medicare-Covered Services

Beneficiaries receiving services under Medicare Part A, including hospital and non-hospital medical services, can appeal a denial of services. There are five levels of appeal, but only the first two (redetermination and reconsideration) can be expedited. (42 C.F.R. § 405.904(a)(2).)

You must follow the correct fast-appeal procedures to challenge an early discharge or termination of services. The steps for an expedited hospital discharge appeal differ from those for filing a fast appeal involving non-hospital settings, such as a skilled nursing facility or hospice facility.

Medicare's Basic Fast Appeal Notice Rules

Whether you're receiving Medicare-covered services in a hospital, SNF, or from another health care provider, your provider must give you a written notice before you're discharged or your services end. That notice includes important instructions for filing an expedited appeal, so if you didn't receive it, ask for it.

Receiving a Hospital Discharge Notice

If you're in the hospital, you should have signed and received a notice called "An Important Message from Medicare about Your Rights" (the IM) within two days of your admission to the hospital. The hospital must also give you a copy of the IM you signed within two days of your scheduled discharge date. You need to have this document to file your expedited Medicare appeal.

The IM contains information about your appeal rights and how to file a fast appeal of your hospital discharge. So, if you don't have it, ask for it. Not following the directions in the IM could affect your costs and appeal rights.

Getting a Termination of Service Notice

If you're receiving home health care or hospice services, you should receive a standard termination of services or discharge notice (called a "Notice of Medicare Non-Coverage") from your health care provider at least two days (or two visits) in advance of the proposed termination or discharge date. This notice will advise you of the following:

• when your Medicare coverage will end
• when and where to file an appeal, and
• whether you'll be financially responsible if you continue to receive services pending your appeal.

If you don't get this notice but are told your services will be terminated or that you'll be discharged, ask for the written notice. Read it very carefully, as it contains essential information about your appeal rights.

How to Request an Expedited Medicare Appeal

Fast appeals are initially filed with an independent reviewer called a Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO, or simply QIO). This organization is made up of doctors and other health care experts under contract with Medicare who will decide whether you should remain in the hospital or continue another Medicare-covered service.

BFCC-QIO's Role in Level 1 Medicare Fast Appeals

You can file your appeal by telephone or in writing. You'll find the name and phone number of the BFCC-QIO for your area in your IM, non-coverage notice, or discharge notice.

You can submit medical records or a letter from your doctor or other health care provider supporting your appeal. And you can contact your local BFCC-QIO if you need help filing your appeal.

After making your request for appeal, the hospital, SNF, CORF, HHA, or hospice agency will send you and the BFCC-QIO a "Detailed Explanation of Non-Coverage" that includes the following information:

• why your Medicare-covered services are no longer reasonable and necessary (or no longer covered)
• the specific Medicare rule used to decide to stop treatment or discharge you, and
• how that rule applies to your situation.

Once you file your fast appeal, the QIO will take the following actions:

• ask why you think you need to stay in the hospital or continue to receive the health care services being terminated
• review your medical records and information from the provider, and
• decide if you're ready to be discharged or for the non-hospital services to end within one day of receiving all the requested information.

Some financial liability rules and deadlines differ depending on whether you're expedited appeal concerns a hospital discharge or termination of other Medicare-covered services, like rehab or hospice care. Be sure to check your IM or non-coverage notice for specific appeal instructions.

Fast Level 1 Appeal Instructions for a Hospital Discharge

You must ask for an expedited hospital discharge appeal no later than the day you're scheduled to be discharged from the hospital. If you miss this deadline, you might still request an expedited review, but different financial responsibility rules and time frames will apply.

While you can't be discharged from the hospital while the BFCC-QIO's decision is pending, you're still responsible for any applicable Medicare copays or deductibles. But as long as you request the review on time, you can't be held liable for the full cost of your care while you await the QIO's decision. (42 CFR § 422.622(b)(4).)

If the BFCC-QIO decides in your favor, you can stay in the hospital for as long as it's medically necessary, and Medicare will pay for your care. You'll pay only your regular coinsurance and deductibles.

If the BFCC-QIO decides you should be discharged, Medicare will cover the cost of your hospital stay until noon of the day after you get the BFCC-QIO's decision. After that time, if you continue to receive inpatient hospital services, you could be required to cover all of the costs yourself.

Level 1 Fast Appeal of Other Medicare-Covered Services

You have until noon on the first day after you receive the termination of services or discharge notice to request an immediate review from the BFCC-QIO. Note that if you miss the fast appeal deadline, you can still request an expedited review, but the QIO doesn't have to make a decision as quickly, and you get no financial liability protection unless the BFCC-QIO decides in your favor. (42 CFR § 422.626(a)(2).)

If you're appealing a termination of home health care or rehab services, you'll need a licensed doctor to certify that stopping the services could place your health at significant risk. But a doctor's certification isn't required to appeal a Medicare discharge from a skilled nursing facility or hospice care.

If the BFCC-QIO decides you still need skilled nursing, home health, CORF, or hospice services, Medicare will usually continue to pay for these services.

If the BFCC-QIO decides the services should end, Medicare will cover any services you received before the termination date on your non-coverage notice. But you'll likely have to pay for any services you receive after the termination date.

Level 2 Fast Medicare Appeal of Hospital or Health Service Discharge

If the BFCC-QIO decides against you—upholding the discharge or termination of services order—you have the right to appeal to the Qualified Independent Contractor (QIC), another independent review group. (42 CFR § 405.1204(a).)

You have until noon the day after you receive the BFCC-QIO's decision to request a second-level appeal, also known as a Leval 2 appeal or "Request for Reconsideration." You can request a QIC reconsideration in writing or by telephone.

If you decide to stay in the hospital or continue receiving non-hospital services, you could be financially responsible for the cost of the extended care you receive. If it's a hospital discharge appeal, your financial responsibility could start the day after you receive the BFCC-QIO's decision.

If you're appealing a Medicare discharge from rehab or other non-hospital services, you'll generally be responsible for paying for any services received after the termination date on the Medicare non-coverage notice.

The QIC must normally issue its decision within 72 hours of receiving your request for reconsideration. But you can request that this period be "continued," or extended, for 14 days to give you time to collect documentation supporting your appeal. You'll likely need additional evidence showing that continued care is medically reasonable and necessary.

If the QIC can't issue a decision within the 72-hour deadline, it must notify you of your right to "escalate," or take the case directly to the next level of appeal. You could then take your case to an administrative law judge (ALJ) without waiting for the QIC decision.

Further Levels of Appeal

If you receive an unfavorable Level 2, QIC reconsideration decision—meaning Medicare won't cover or pay for your continued stay in the hospital or a skilled nursing facility or for continued services from a comprehensive outpatient rehabilitation facility, home health agency or hospice agency—you have three remaining levels of appeal:

• a Level 3 hearing with an administrative law judge (ALJ)
• a Level 4 request for review from the Medicare Appeals Council (MAC), and
• filing a lawsuit in United States District Court.

Each of these levels has different timelines and minimum required amounts in dispute. The QIC's decision will contain instructions for a Level 3 appeal, requesting a hearing from an administrative law judge.

(To learn more about these last three levels of appeal, read our article on regular appeals of Medicare Part A.)

Get Help With a Medicare Hospital Discharge or Service Termination Appeal

For more information on Medicare's expedited appeals process, visit the Medicare website's fast appeals area. If you need help filing your appeal, you can contact:

• your State Health Insurance Assistance Program (SHIP)
• the Center for Medicare Advocacy, or
• a Medicare lawyer.