November 17, 2023

Medicare, as a crucial component of the American healthcare system, provides significant protections for senior citizens, ensuring they are not discharged prematurely from hospitals or nursing homes.
By covering extended stays in hospitals and skilled nursing facilities, Medicare ensures that seniors receive the comprehensive care they need. This is particularly important for those recovering from surgeries, strokes, or other major health events. Premature discharge can lead to a host of complications, including readmission to the hospital.
How Medicare prevents premature discharge
Medical necessity as a criterion: As long as a patient’s doctor deems continued care in a hospital or skilled nursing facility necessary, Medicare will continue to provide coverage. This decision is based on a thorough assessment of the patient’s health status, progress, and potential risks associated with early discharge.
Regular assessments and reviews: Medicare requires regular assessments of patients’ health status. These evaluations are conducted by healthcare professionals to determine whether the patient is ready to be discharged. If the team concludes that the patient needs more time to recover, Medicare will continue to cover the stay.
Rights and appeals process: Seniors on Medicare have rights and a structured appeals process if they believe they are being discharged prematurely. They can file an appeal if they feel their care is being ended too soon, which triggers a review process.
How to appeal a discharge decision
If you believe that a hospital or nursing home is planning to discharge you or a loved one too soon, you can take several immediate actions to advocate for the patient’s right to stay and receive the necessary care:
- Request a detailed explanation. Ask the nursing home or hospital staff for a clear, detailed explanation of why they believe the patient is ready for discharge. Understanding their rationale is crucial for any subsequent steps you may take.
- Speak with the healthcare providers. The patient or their healthcare power of attorney should talk directly to the doctors and nurses responsible for the patient’s care. Express your concerns and ask for their assessment of the patient’s condition. Sometimes, additional information from family members can influence their decision.
- Invoke Medicare rights (if applicable). Patients who are covered by Medicare have specific rights under the program, including the right to an appeal if they are being discharged from a hospital or skilled nursing facility.
- Notice of Medicare non-coverage: The facility should provide a “Notice of Medicare Non-Coverage” prior to discharge. This notice explains how to appeal the decision.
- Immediate appeal: You can file an immediate appeal with the Quality Improvement Organization (QIO) in your state. The appeal must be filed promptly (usually within the timeframe specified in the notice). During the appeal process, Medicare will continue to cover the patient’s stay.
- Contact the long-term care ombudsman. Reach out to your state’s long-term care ombudsman program. The ombudsman advocates for residents’ rights in nursing homes and can assist you in understanding your rights and the steps you can take.
- Keep documents. Gather all relevant medical records, notes from healthcare providers, and any other documents that support the need for continued care. This information can be critical during an appeal process.
- Explore legal assistance. If you encounter significant challenges, consider consulting with an attorney specializing in elder law. They can provide guidance on legal rights and may assist in the appeal process.
- Discuss with the administration. Have a conversation with the administration of the nursing home or hospital. They might reconsider the discharge plan or offer alternatives based on your concerns.
- Seek support from advocacy groups. There are various senior advocacy groups and community resources that can offer assistance and advice in such situations. Your local area agency on aging can be a good starting point.
- Prepare for alternative plans. While you are appealing the discharge, it’s also wise to consider and prepare for potential alternatives, such as home health care or another facility, in case the appeal does not result in a decision to continue the current level of care.
Acting swiftly and understanding your rights are crucial in this process. The key is to engage with the right entities (like the healthcare team, Medicare, and the ombudsman) and to ensure that any appeal or complaint is filed within the required timeframes.