Two times you may need to appeal a decision for the denial of Medicare benefits is when you are in the nursing home or in the hospital. There is no time to consult with a lawyer. Indeed, lawyers are of little use when you or your family member are hurting and need treatment. What you need is to get your doctor involved as fast as possible and take action.

Nursing Home Appeals

Medicare beneficiaries should seek “expedited review” of a skilled nursing facility, home health, hospice or comprehensive outpatient rehabilitation facility (CORF) services discharge or termination.

Expedited review is available in cases involving a discharge from the

provider of services, or a termination of services.

A reduction in service is not considered a termination or discharge for purposes of triggering expedited review except in the case of skilled nursing facility care when the reduction of care from daily to intermittent will mean that the beneficiary is no longer eligible for Part A coverage. Coverage under Part B is very expensive for you the consumer. You must fight the reduction in care.

For home health care and CORF services, a successful appeal requires that a physician certify that “failure to continue the provision of such services is likely to place the individual’s health at risk.”

The provider must give the you, the Medicare beneficiary a general,

standardized notice at least two days in advance of the proposed end of the service. If the service is fewer than two days, or if the time between services is more than two days, then notice must be given by the next to last service. The notice describes the service, the date coverage ends, the beneficiary ‘s financial liability for continued services, and how to file an appeal.

A beneficiary who wishes to exercise the right to an expedited

determination must submit a request for a determination with the Qualified Independent Organization or Contractor, (“QIO” or “QIC”) in the state in which the beneficiary is receiving the services at issue. The request may be made in writing or by telephone, but the request must be made no later than noon of the calendar day following receipt of the provider ‘s notice of termination.

If the QIO is unavailable to accept the beneficiary’s request, the beneficiary must submit the request by noon of the next day the QIO is available. At that time, the beneficiary is given a more specific notice that includes a detailed explanation of why services are being terminated, a description of any applicable Medicare coverage rules and information on how to obtain them, and other facts specific to the beneficiary’s case. The beneficiary is not financially liable for continued services until two days after receiving the notice, or the termination date specified on the notice, whichever is later.

Coverage of the services at issue continues until the date and time

designated on the termination notice, unless the QIO reverses the

provider’s service termination decision. If the QIO’s decision is delayed because the provider did not timely supply necessary information or records, the provider may be liable for the costs of any additional coverage, as determined by the QIO. If the QIO finds that the beneficiary did not receive valid notice, coverage of the provider services continues until at least 2 days after valid notice has been received. Continuation of coverage is not required if the QIO determines that coverage could pose a threat to the

beneficiary ‘s health or safety.

If the QIO upholds the decision to terminate services or discharge the beneficiary, the beneficiary may request expedited reconsideration, orally or in writing, by noon of the calendar day following the QIO’s initial notification. The reconsideration will be conducted by the QIC, which must issue a decision within 72 hours of the request. If the QIC does not comply with the time frame, the beneficiary may “escalate” the case to the administrative law judge level.

Medicare beneficiaries retain the right to utilize the standard appeals

process rather than the new expedited process in all situations. A QIO may review an appeal from a beneficiary whose request is not timely filed, but the QIO does not have to adhere to the time frame for issuing a decision, and the limitation on liability does not apply.

Special Rules for Hospital Claims

Hospital inpatients denied Medicare during their stay may request an “expedited review” of a Medicare denial by the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). This link will take you to the telephone numbers and website.

A beneficiary may request reconsideration review by the QIC for an

unfavorable decision. If the reconsideration decision is unsatisfactory and the amount in controversy is sufficient, the beneficiary may request an ALJ hearing. Hearing requests must be made within 60 days of receipt of the notice of the reconsideration decision. The hearing request should be made in writing and should be filed with the entity identified in the reconsideration notice.

If the hearing request is unsatisfactory, a beneficiary may request a review from the Medicare Appeals Council (MAC). The request must be made within 60 days of receipt of the hearing decision. If, after the hearing, the amount in controversy meets the requirements the case may proceed into United States District Court.

Several self-help packets are available at the Center for Medicare Advocacy, upon which this article is based. The link below will connect you to them.

https://medicareadvocacy.org/take-action/self-help-packets-for-medicare-appeals/

Again, the key is to get your physician involved as soon as possible. Do not rely upon the hospital or nursing home physician who may not support you or be available in a timely manner.