Since my mother got sick last fall, nothing has been more frustrating than dealing with the institutional forces that constantly want to send her home before she’s ready. Early in the process, we were able to negotiate our way through it. But recently we got handed Medicare discharge orders at the skilled nursing rehab where she went after a hospital stay for a back injury.
We appealed. We won.
Then they tried to discharge her a week later, and we appealed again. And won.
Part A of Medicare technically covers 90 days of inpatient hospital care and 100 days of skilled nursing rehabilitation. The reality is that you have to be authorized by the facility to use all of those days. Most of the time, they discharge you much sooner. Sometimes, that’s a good thing, because those limits are per incident, not per calendar year, and if you have another issue and have to be readmitted before 60 days have elapsed – even for a separate issue – it counts as the same stay. Because of the risk of running out of coverage, or dipping into the 60 extra lifetime reserve days Medicare provides, you might want to preserve some days just in case.
But for the most part, being discharged from Medicare coverage sooner than you would like means you go home to a possibly less-than-ideal care situation and risk things like infection and injury from falls. Or you stay and pay.
In my mom’s case, going home right then wasn’t really an option, and losing Medicare coverage would have cost us $499 a day. For our first appeal, which came about 60 days into her rehab stay, I calculated that my mom’s remaining Medicare days were worth roughly $20,000. That was definitely worth fighting for, so we dove into the appeals process to try to use the rest of the 100 days, or as many of them as we could.
Medicare does not release exact statistics about the success of Part A discharge appeals, just the number of appeals and the time to resolution that is aggregated with other Medicare coverage areas. Patients who lose their first appeal can file for a second and third reconsideration, but the catch with those is if you lose, you owe the facility for the days not covered. Boomer Benefits, a Medicare plan broker that provides appeals assistance, says its counselors find that patients win only about 20% of discharge appeals, but the organization usually only hears about cases where people are a long way into the process and stuck.
“When people reach out, they’ve generally exhausted what they can do on their own. We hear the bad part of it, and we try to resolve it from there,” says Lauren Bigham, a Medicare agent for Boomer Benefits.
Here’s what we needed to know to get through the process:
Be meticulous and persistent
When a facility schedules a person for discharge from Medicare coverage, you’ll get an official “Notice of Medicare Non-Coverage” that tells you how to file a fast appeal, which you need to do within 48 hours. The No. 1 tip: Don’t miss the deadline.
But your process actually needs to start well before you get this notice, with you carefully building your loved one’s case by making sure that everything is documented in the facility’s file.
You’ll get a chance to state your case – briefly, verbally – when you file the appeal, but you likely won’t get to submit your own paperwork. So you need to make sure that the doctors make their notes clear, that medication changes are written down and that the long-term goals are clear.
“A good chunk of doctors are able to help out, especially if it’s not an emergency,” says Bigham. Asking nicely as you are persistent is always helpful.
You have to be right
For your appeal to work, the most important factor is that you have to be right. The patient needs to have a legitimate reason why they should stay in the hospital or the skilled nursing facility, and that need has to jump off the paper. That’s because the fast appeal triggers an independent review to determine whether covered services should continue, according to Medicare, and all the reviewer is going to look at is the record.
“They’re kind of going by the CMS manuals that have coverage guidelines – a patient needs this much nursing, this much physical therapy, and you don’t meet these standards. It’s not the human side of things,” says Sarah Murdoch, director of client services at the Medicare Rights Center.
That’s why you need the doctors to write good notes. It might sound obvious based on what’s wrong with the patient, but you need them to specify things like, “Mary Jones suffered a broken hip and is recovering, but needs continued physical therapy in a rehab facility for at least three more weeks until I can assess her at her next checkup.” Or perhaps a doctor is just trying out a new medicine and you can document that in the record and have them ask for more time to evaluate how it’s working, if it’s a medicine that needs medical monitoring.
“If Medicare is saying you don’t need the facility, but providers are saying you do, those appeals are much more likely to win,” says Murdoch.
Where to get help
Your first stop for help is the institution, whether it’s a hospital or skilled nursing facility, which should have a social worker or patient representative who can help direct you to resources. You can also reach out directly to Medicare, but mostly as a repository of the basic rules.
“If you call Medicare, they’ll likely read to you directly off the website,” says Bigham. “Make sure to do more research. Every state and county has different rules.”
Organizations like the Medicare Rights Center, the National Council on Aging, AARP and Boomer Benefits have counselors available, and you can also go to state health insurance assistance agencies.
“Persistence is very important. People think as long as they did the first step, then that’s that, but you have to keep at it,” says Murdoch.
We have learned that lesson well in my family. After my mother’s two appeals victories in a row, we were able to negotiate with the facility for a little, so my mom is continuing rehab and closing in on the end of her full 100 days of Medicare coverage. We’re making plans for what’s next, and we await our next move.