Medicare provides for independent review of discharge decisions: Healthy Cleveland

Medicare provides for independent review of discharge decisions: Healthy Cleveland

by Diane Suchetka/Plain Dealer Reporter
Tuesday August 04, 2009, 10:00 AM

Healthy Cleveland / Consumer Advice

Diane Suchetka

Did you know that if you're on Medicare, you don't have to leave a hospital just because a doctor discharges you?

If you think you're too sick to leave, you can ask Medicare to review your case. And while that review is under way -- it usually takes a day or two -- Medicare will continue to pay for your stay.

The rule doesn't just apply to hospitals.

It's true for nursing-home and rehabilitation-center stays and home health care, too.

And requesting a review is simple.

It's probably a good idea to understand the process before you find yourself in a hospital or nursing home. Your spouse, children and caregivers ought to know about it, too, in case they have to speak up for you.

The key reason is this: If you want a review, you should request it before being discharged. If you're already out the door, you can still ask for one, but it makes it harder to get the results you want.

Of course, the ruling won't always be in your favor -- not by a long shot.

Of the 1,548 reviews conducted in Ohio this past year, only 187 resulted in Medicare paying for extended stays, according to those who oversee them. That's about 12 percent.

One in five Medicare patients ends up back in the hospital within a month of being discharged, according to a study that appeared in the New England Journal of Medicine earlier this year. And those re-hospitalizations cost Medicare -- which taxpayers pay for -- billions of dollars a year.

You and your family should also know that Medicare won't keep paying for your care just because you want it to. There has to be a medical reason -- and a sound one -- for Medicare to continue picking up the tab. If you're in a rehabilitation center, for example, and you're still making progress in physical therapy but haven't reached your goals, Medicare should continue to cover your costs.

It's nearly impossible to list the circumstances under which Medicare will or won't cover the charges. Every case is different.

"But if you don't need the acute-care services of a hospital, quite honestly, you're much safer outside of a hospital," says Dr. Ronald Savrin, medical director of Ohio KePRO.

Patients can pick up staph infections, pneumonia and deadly bugs like C. diff in hospitals and nursing homes.

Ohio KePRO is the company Medicare has hired to make sure that the 1.8 million Ohio citizens 65 and older who are covered by the government-funded insurance get the care they're entitled to. It also works to improve that care, which is why it's called Ohio's Medicare QIO, short for Quality Improvement Organization.

It's Ohio KePRO that you call when you want a review.

Here's its advice on how to appeal your discharge. Know that these are the steps you take whether you're covered by Medicare's fee-for-service plan or Medicare Advantage, sometimes referred to as a Medicare HMO.

1.) If you're about to be discharged or your home health care is about to end and you think it's too soon, talk to your doctor or home health-care agency first and explain why you think your care should continue.

"Clearly the first avenue is to talk to your physician," Savrin says. "That discussion can lead to a resolution."

2.) If that doesn't lead to a resolution, you or your representative should call Ohio KePRO's Beneficiary Help Line, 1-800-589-7337 before you leave the hospital. Choose Option 2 and ask for a review. That review begins with someone from Ohio KePRO talking to you or your family about why you feel you shouldn't be discharged.

"In most instances we like to talk directly to the patient, if they're capable," says Jennifer Bitterman, Ohio KePRO's director of review services. "If they'd rather have us talk to the son, the daughter, we will. But we want confirmation that they're in agreement with the appeal. The reason we do this is because this is considered a patient right."

Ohio KePRO will then request a copy of your records from the hospital or health-care institution and talk to caregivers there. Then it calls in an outside doctor -- one who specializes in the type of care you're receiving -- to review your case.

Ohio KePRO will call you back with a decision, by phone, within 24 to 48 hours, in most cases. And it will follow up with a letter. If it decides that you're ready to be discharged, you can still stay, but you'll have to pay for the care from that point on. If it decides you should stay, Medicare will continue to cover your costs until you're medically ready to be discharged.

Here's one more important piece of information: While the review is going on, the institution cannot charge you for the care you're receiving.

3.) If you don't like the decision, you can appeal. To do this, you call Ohio KePRO again. This time, another outside doctor will be called in to review your case.

There's a key difference between the initial review and this appeal. If Ohio KePRO decides, on appeal, that you should be discharged you must pay for the care you received while the appeal was under way.

There are other appeal options after that, but few patients take them. If you're interested in doing so, you can call Ohio KePRO, once again, for details on how to do so.

"We are here to protect the beneficiary," Bitterman says. "We want to make sure that every patient is getting the care that they need."

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