You can appeal a hospital discharge decision if you you feel your mom is being dismissed too quickly or if you feel unprepared to take her home from the hospital. The discharge planner cannot legally release your mom from the hospital until the appeal is reviewed and a decision handed down. This appeal period will give you more time to prepare for her care.
Your mom was admitted to the hospital with pneumonia. After two weeks of treatment, she recovered and no longer needs hospitalization. You are relieved that Mom is better and life will soon return to order. Then suddenly the hospital gives you a written notice that Mom must leave the hospital in the next 24 hours! Oh no! You knew she would be going home soon, but you don’t think she’s ready yet. The hospital will arrange a “safe discharge”, which means, they will arrange for her to leave the hospital with referrals for all the services she needs to be well cared for outside the hospital. But there is a lot you must be prepared to handle.
After an acute illness and hospital stay, most elderly folks will require physical, occupational and/or speech therapy to rebuild their strength. You will probably be faced with one of two scenarios: 1) your mom will require therapy at a nursing home rehabilitation center or 2) she will be sent home with home health care.
In the first scenario, your mom will go to a nursing home for a period of time. Traditional Medicare will pay up to 100 days of rehab. It pays the total amount for the first 20 days; and 80% for the remaining days up to 100 days. The other 20% will be picked up by a secondary insurance plan or paid out of pocket. If she has one of the Medicare Advantage plans (such as Health First or Aetna Medicare), the coverage will be individualized based on her plan.
If this is the recommended option, the discharge planner will ask you to suggest up to five nursing homes that she can contact for a referral. What are your options, if faced with this situation?
1. The ideal option is that you have already researched nursing homes ahead of time, just in case you are faced with such a crisis. You had anticipated this situation before hand and had the forethought to do some legwork. You can pat yourself on the back for your foresightedness.
2. A second option is to ask the hospital discharge planner for recommendations. The discharge planner will know about some nursing homes in the area and can offer suggestions but beware most discharge planners are too busy to go out to visit nursing homes to make personal decisions. They rely on information that has been provided by nursing home representatives who visit hospitals.
3. Another option is to ask friends,doctors, senior centers, and social workers to make suggestions. At least you will be talking to people who have known patients who have had personal experience.
4. There is a fourth option that I will discuss at the end of this article.
If you are offered the second scenario and your mom will be going home, the discharge planner will make arrangements for intermittent services to be put in place. This may include occasional nurse visits, some home assistance to help your mom with daily personal care (such as bathing)—and possibility some rehabilitation therapy. Medicare will pay for these intermittent services. But beware these services cover only 3-4 hours per day at the most, and most of the time, therapy is only given 2-3 days a week. Feel you need more time to prepare?
In this case your options are:
1. Stay with Mom yourself until a nurse can come in and assess her needs.
2. Ask a friend or relative to stay with Mom until help can be put in place.
3. Hire someone to care for Mom until she is assessed and services are put in place.
4. Apply the fourth option—the same as in the first scenario.
What is the fourth option? The fourth option is to appeal the hospital decision. Tell the hospital that you feel your mom is being dismissed too quickly and ask to have an outside party review the discharge. The discharge planner cannot legally release your mom from the hospital until the process is reviewed and a decision handed down. This appeal period will give you more time to research nursing homes or prepare at home.
How is this done?
Every state has a Quality Improvement Organization, (QIO), that will intervene when a person wishes to appeal a discharge from a hospital. A QIO is a private, usually not-for-profit organization that is staffed by health care professionals who are trained to review medical care and determine if a case has merit. While the QIO is reviewing your appeal your mom can remain in the hospital—at no cost— until a decision is made.
Within two days of your mom’s admission, every patient is given a written notice called “An Important Message from Medicare about Your Rights”. This lists the QIO’s contact information and explains the steps in appealing a hospital decision. To start the appeal process you must contact your state’s QIO with a request for an appeal no later than 11:59 p.m. on the day of your proposed discharge. If the QIO decides that you are ready to be discharged and you met the deadline for requesting a fast appeal, you won’t be responsible for paying the hospital charges (except for applicable coinsurance or deductibles).
But you must work quickly; these appeals are handled promptly. They can be reviewed within a one- to two-day time period. So use the time wisely. If you need to research nursing home rehab centers, start making calls and touring different facilities. If you are preparing for your mom to return home, start making arrangement—make sure someone is available to stay with her until services are put in place. Arranged the furniture so Mom can get around with her new walker or wheelchair; go shopping to insure you have enough food and adequate medical supplies; and don’t forget the flowers!
Not many families know about this appeal process but by knowing your rights, a family can take charge of these emergency situations. You can make sure all your needs are in place for a really safe hospital discharge. And it is on your own terms.
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