You have the right to receive all the hospital care that is necessary for the proper diagnosis and treatment of your illness or injury. According to Federal law, your discharge date must be determined solely by your medical needs, not by "DRG's" (diagnosis-related groups) or Medicare payments.
You have the right to be fully informed about decisions affecting your Medicare coverage and payment for your hospital stay and any post-hospital services.
You have the right to request a review by a Peer Review Organization of any written Notice of Noncoverage that you may receive from the hospital stating that Medicare will no longer pay for your hospital care. Peer Review Organization (PRO's) are groups of doctors who are paid by the Federal Government to review medical necessity, appropriateness and quality of hospital treatment furnished to Medicare patients. The phone number and address of the PRO for your area are:
You and your doctor know more about your condition and your health needs than anyone else. Decisions about your medical treatment should be made between you and your doctor. If you have any questions about your medical treatment, your need for continued hospital care, your discharge, or your need for possible post-hospital care , don't hesitate to ask your doctor. The hospital's patient representative or social worker will also help you with your questions and concerns about hospital services.
If You Think You Are Being Asked to Leave The Hospital Too Soon
Ask a hospital representative for a written notice of explanation immediately, if you have not already received one. This notice is called a "Notice of Noncoverage." You must have this Notice of Noncoverage if you wish to exercise your right to request a review by the PRO. The notice of Noncoverage will state either that your doctor or the PRO agrees with the hospital's decision that Medicare will no longer pay for your hospital care.
If you do not request a review, the hospital may bill you for all the costs of your stay beginning with the third day after you receive the Notice of Noncoverage. The hospital, however, cannot charge you for care unless it provides you with a Notice of Noncoverage.
If the Notice of Noncoverage states that your physician agrees with the hospital's decision:
If the Notice of Noncoverage states that the PRO agrees with the hospital's decision:
NOTE: The process described above is called "immediate review". If you miss the deadline for this immediate review while you are in the hospital, you may still request a review of the Medicare's decision to no longer pay for your care at any point during your hospital stay or after you have left the hospital. The Notice of Noncoverage will tell you how to request this review.
When your doctor determines that you no longer need all the specialized services provided in a hospital, but you still require medical care, he or she may discharge you to a skilled nursing facility or home care. The discharge planner at the hospital will help arrange for the services you may need after your discharge. Medicare and supplemental insurance policies have limited coverage for skilled nursing facility care and home health care. Therefore, you should find out which services will or will not be covered and how payment will be made. Consult with your doctor, hospital discharge planner, patient representative and your family in making preparations for care after you leave the hospital. Don't hesitate to ask questions.