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Michigan Elder Law Today

Sunday, July 15, 2012

Hospital Discharge Issues

When an elderly person is admitted to the hospital, it’s a stressful event.  A situation that can compound that stress is if the hospital wants to discharge your older parent or other loved one before you feel they are ready to be discharged.  Hospital discharge issues tend to occur more after unplanned hospitalizations, such as if an older person was admitted to the hospital after a medical emergency, be it a stroke or fall resulting in broken bones.  While it is true that the hospital cannot just force a patient to leave, they can began charging the elder for the hospital’s services if they stay after the hospital recommends a discharge.  That could be very expensive, but as a person entitled to Medicare, your older parent has certain rights and can appeal a hospital’s decision to discharge them.  Even if the appeal is not won, the appeal process may result in extra days of Medicare coverage in the hospital.

The current Medicare rules require hospitals to give certain notices, one after admission and one before discharge.  The first notice is supposed to be given two days after being admitted to the hospital and is entitled “An Important Message from Medicare about Your Rights.”  The notice explains the patient’s discharge and appeal rights.  The patient is supposed to read, sign, and date the notice.  The notices are routinely given by the hospital but may get lost in the shuffle and of the older person’s medical crisis.  The patient often is not in a position to understand them, and the family, who may be overwhelmed by mom or dad’s medical crisis may not take time to read and understand the notice. 

Two days before the date of discharge, the hospital is supposed to give the patient another copy of the Important Message from Medicare.  However, the second notice is not required if the hospitalization was for 3 days or less.  Many people are surprised at the short hospital stays recommended after a previously healthy senior has suffered a major medical crisis, such as a stroke or broken hip.  These events are often a family’s first introduction to the short and long term care system for the elderly and sometimes it may feel like the hospital is trying to rush the patient out.  The reason these short hospitalizations occur is if Medicare and/or the patient’s supplemental health insurance company later determine the patient did not need to be hospitalized for some days making up the period of the hospitalization, the hospital may have a hard time getting paid.

You may request a hospital discharge review if you:

  • Believe you, or your loved one, is not medically ready to go home from the hospital;
  • There is a legitimate medical reason to continue receiving a medical service; or
  • Your have not received clear discharge instructions.

If your elderly loved one has received a discharge decision and you feel they are not ready to be discharged from the hospital, you would need to contact the local Medicare Quality Improvement Organization (QIO).  The QIO’s telephone number should be on the Medicare notice.  A QIO is a group of physicians and other health care professionals who monitor the care provided to Medicare beneficiaries.  The QIO will review the hospital’s decision to discharge.  The QIO staff is paid by the U.S. government and is not affiliated with the hospital.

There are time limits to contact the QIO, so if you are going to appeal the discharge, it should be done quickly.  The QIO must be contacted by noon of the first business day of the day after you receive the discharge notice.  If the QIO is contacted in a timely manner, the patient does not have to pay for their care while they wait for the QIO to review the discharge

Once the QIO is notified, the hospital must produce a Detailed Notice of Discharge no later than noon the day after you requested a review.  This notice must detail the medical decisions supporting the discharge.

The QIO will then review the discharge, including the medical necessity of a continued hospitalization.  The hospital cannot discharge the patient during this review and the patient does not have to pay for these additional days in the hospital.  In effect, this extends Medicare coverage.  The QIO must issue its decision within three days.  Even obtaining these three additional days of hospitalization may have a beneficial effect on the older person.

For instance, some elderly people may have become weak from dehydration or lack of eating in the days leading up to the medical emergency that led to the hospitalization.  Often, with unplanned hospitalizations, the elder is going to be discharged to a skilled nursing facility (nursing home) first, not directly back to their home.  If the hospital wants to discharge them to a nursing home for skilled physical therapy too quickly, they may not be strong enough to participate in rehab in the nursing home. This can result in the loss of the limited nursing home coverage that Medicare provides there and a premature diagnosis by the nursing home staff that the elder needs 24-hour nursing home care.  It may be that if the elder can receive a few extra days in the hospital, they will be strong enough to participate in rehab in the nursing home, which may then result in them being able to recover enough to return home, instead of having to move a nursing home at that time.  As such, considering an appeal of an early hospital discharge is important.

If the QIO agrees with the hospital’s decision to discharge, the next step is you could appeal to an administrative law judge.  This is a more complicated process and you might need a lawyer.  If you lose the appeal before the administrative law judge, in some instances you can appeal to federal court, though such actions are rare.  Families are usually too overwhelmed their loved one’s health crisis to make a federal case of it.

The QIO for Michigan is an organization called MPRO.  Their telephone number is  1-800-365-5899.

If you receive a hospital discharge notice, you will likely be dealing with someone who works for the hospital called a discharge planner or a social worker.  One of the discharge planner’s jobs is to find a skilled nursing facility that has space available to admit a new patient who needs skilled rehab services in the nursing home.  The nursing homes are usually happy to receive these patients, but the nursing home that has space available may not be to your liking or your first choice.  You will need to work with the discharge planner and remember that, while part of their job is to help arrange a safe and appropriate discharge, they are not the decision maker regarding the discharge.  The doctor and medical staff are.  Also, the discharge planners may be dealing with a high case load, so they may not be able to give as much individual attention to a family’s needs as one may want.  When people are overwhelmed by their elderly loved one’s health crisis, which may involve difficult emotions of dealing with an older parent’s decline and possible need for long-term care, people can become distraught or angry and the discharge planner may have this frustration directed at them.  If you are in this situation, try to step back and keep a cooperative attitude.  Even if you win the QIO appeal and receive extra Medicare days in the hospital, your elderly loved one will be discharged from the hospital at some point and, if they are going to be discharged to a nursing home, you will need the discharge planner’s help in finding a good one.

An elderly person’s hospitalization under Medicare Part A is a sign to become proactive and consider your loved one’s future.  As an elder law attorney, one of the ways I can help is with my long-term care planning process.  Our next post will discuss Medicare Part A’s limited skilled nursing facility benefit, which is one of the issues considered in a long-term care plan.


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