Medicare Part A - Acute Care
A Quick Screen To Aid In Identifying Coverable Cases
Medicare claims for inpatient hospital care are suitable for Medicare coverage, and appeal if they have been denied, if they meet the following test:
The patient's condition must have been such that the care he required could only have been provided in a hospital, or he required a skilled nursing facility (SNF) level of care, and no SNF bed was actually available. (Note: A SNF level of care means that the patient required skilled services - from a physical therapist or a registered nurse, for example - on a daily basis.)
Additional Advocacy Tips:
The opinion of the patient's attending physician is the most important element in your case. If the physician believes that it was medically necessary for the patient to receive care in the hospital, or that he needed at least a skilled nursing facility level of care but no skilled nursing facility bed was actually available, you probably have a winning case.
Ask the attending physician to put his or her favorable opinion in writing, explaining with as much detail as possible why the coverage standard described above is met in the patient's case.
Usually a Medicare denial means not that the patient must leave the hospital, but that any further stay will be at his own expense. Remember, however, that the patient cannot be required to pay unless he has been given a written notice of denial of coverage, and once a written denial is delivered he cannot be charged until the third day following the notice. Example: denial notice delivered on Monday, the patient can be charged for his stay beginning Thursday.
Appeal as quickly as possible. In some cases the patient is entitled to "expedited" review, which may include additional time in the hospital before charges accrue, if you request a review immediately. The Medicare denial notice given by the hospital will tell you how to immediately appeal by calling the Connecticut Peer Review Organization.
The hospital may charge a beneficiary for services received in the hospital only if all of the following conditions have been met:
The hospital must determine that the patient no longer requires in-patient hospital care (the phrase "in-patient hospital care" includes cases where a beneficiary needs skilled nursing facility care, but a skilled nursing facility bed is not available.)
The attending physician agrees with the hospital determination in writing, or, if the hospital is unable to obtain an agreement from the physician, the QIO concurs in the hospital’s determination.
The hospital must notify the beneficiary in writing that the beneficiary no longer requires in-patient hospital care; that customary charges will be made for continued hospital care beyond the second day following the date of the notice; that the QIO will make a formal determination on the validity of the hospital’s finding if the beneficiary remains in the hospital after he or she is liable for charges; that the hospital’s denial decision is appealable, and that any charges for continued care will be refunded if a finding is made on appeal that the patient did require continued in-patient hospital care.
On July 2, 2007, per the Centers for Medicare & Medicaid Services (CMS) a final rule became effective which governs notification to Medicare beneficiaries of their hospital and critical access hospital discharge appeal rights. As an aide to beneficiaries and their advocates, we have provided several key documents related to this rule:
Memorandum from Thomas E. Hamilton, Director of the Survey and Certification Group at CMS, to State Survey Agency Directors regarding the implementation of the final rule.
CMS standardized hospital discharge notice, "An Important Message from Medicare about Your Rights."
CMS standardized hospital discharge notice in Spanish, "Mensaje Importante de Medicare sobre Sus Derechos."
MEDICARE APPEALS PROCESS
A beneficiary’s right to appeal a denial of Medicare hospital coverage varies upon whether the attending physician has agreed that in-patient hospital care is no longer necessary. If the attending physician has not agreed, the hospital must obtain the approval of the QIO before it may issue a denial notice to the beneficiary and begin to charge for services rendered. A determination by a QIO that in-patient hospital services are no longer necessary is an Initial Denial Determination subject to appeal. In such cases the beneficiary may immediately request a Reconsideration of the denial by the QIO. The Reconsideration Request must be filed within 60 days after receipt of the Notice of Denial.
Normally reconsideration determinations are issued by the QIO within 30 days after the receipt of the reconsideration. However, in situations where the QIO has denied admission based on pre-admission review, or where the beneficiary is still an in-patient, reconsideration may be sought and determined on an expedited basis. The beneficiary must submit a Request for Reconsideration within 3 days of receipt of the denial notice. The QIO must then issue its reconsideration determination within three working days after receiving the request if the beneficiary is still awaiting hospital admission, or is currently a hospital in-patient for the stay in question.
In cases where the attending physician agrees that the hospital discharge is appropriate, however, the hospital will not normally obtain QIO agreement before issuing a denial notice to the patient and assessing charges for services rendered. In such cases the beneficiary has the right to request an expedited review by the QIO. The following apply if the beneficiary requests QIO review before noon of the first working day after a written denial notice is properly delivered:
The hospital must provide written records to the QIO by the close of that first working day and;
The QIO must issue a review decision within one full working day after the date the QIO received the Review Request and records.
If the patient requests a speedy QIO review as described above, the hospital may not charge the patient for any charges incurred before noon of the day following the day on which the QIO review determination is received by the patient. If the patient is dissatisfied with the result of the QIO review, he or she may still request a reconsideration of that decision. The rules pertaining to reconsideration described above would pertain.
If the patient is dissatisfied with the result of the QIO reconsideration, and the amount in controversy is at least $120, he or she may obtain a hearing by an administrative law judge of the Social Security Office of Hearings and Appeals. This administrative hearing must be requested within 60 days after receipt of the reconsideration decision.