Medicare Minute: Ending Care Appeals

If you are receiving care in a hospital or non-hospital setting and are told that your Medicare will no longer pay for your care, you have the right to a fast appeal if you feel that continued care is medically necessary. There are separate processes for hospital and non-hospital appeals. Non-hospital care includes care from a skilled nursing facility (SNF), Comprehensive Outpatient Rehabilitation Facility (CORF), hospice, or home health agency. You can appeal by following the instructions on the notices you receive.

Hospital Discharge Appeal

Important Message from Medicare: Your provider should give you this notice within two days of entering the hospital as an inpatient. This notice includes instructions for how to appeal.
Beneficiary and Family Centered Care- Quality Improvement Organization (BFCC-QIO): To file an expedited appeal, call the BFCC-QIO by midnight of the day of your discharge.
Detailed Notice of Discharge: Once you contact the BFCC-QIO, the hospital must send you this notice. It explains in writing why your hospital care is ending.
The BFCC-QIO should call you with its decision within 24 hours of receiving all the information it needs.

Non-Hospital Discharge

Notice of Medicare Non-Coverage: You should receive this no later than two days before your care is set to end. If you receive home health care, you should receive this notice on your second-to-last care visit. This notice tells you when your care is ending and explains how to appeal.
BFCC-QIO: File an expedited appeal by noon of the day before your care is set to end.
Detailed Explanation of Non-Coverage: Once you contact the BFCC-QIO, your provider should give you this notice. It explains in writing why your care is ending.
If you have Original Medicare, the BFCC-QIO should make a decision no later than two days after your care was set to end. If you have a Medicare Advantage Plan, the BFCC-QIO should make a decision no later than the day your care is to end.

Ending Care Appeals

If the appeal to the BFCC-QIO is successful, your care will continue to be covered, including for the time you were appealing. If the BFCC-QIO decides that your care should end, you can file a second appeal within the timeframe on your BFCC-QIO denial notice.

There are five levels of appeal in total. The timing and agency involved depends on which type of care is ending and whether you have Original Medicare or a Medicare Advantage Plan.

Tips for filing Medicare appeals for care that is ending
• Follow instructions on the notices you receive.
• Stick to important deadlines.
• Keep original copies of information.
• Take thorough notes while appealing.
• Request a letter from your doctor or health care provider in support of your continued care to strengthen your appeal.
• Contact your local State Health Insurance Assistance Program (SHIP) for more guidance on appeals.

SNF Medicare Fraud, Errors, and Abuse

Medicare fraud can occur when a provider or facility bills for services you did not receive or were not medically necessary. Examples of potential skilled nursing facility (SNF) fraud:  

- Learning that your Medicare was charged for:
  - Services that your doctor did not deem medically necessary
  - Services that you never received
  - More expensive services than what you received
  - A greater quantity of services than what you received
    SNF services for dates after you were released from the SNF
  - Being forced to stay in a SNF until your benefits have expired, even though your condition has improved, and you wish to transition to home health care services.
- You can stop SNF fraud by:
  - Reading your Medicare statements to compare the services you received with the services Medicare was charged.
  - Reporting any charges on your Medicare statements that are not accurate to your local Senior Medicare Patrol (SMP).
  - Working with your doctor to enroll in SNF services.
  - Not accepting gifts or money in return for choosing a SNF.
  - Signing forms only once you have understood them.
  - Reporting potential fraud to your local Senior Medicare Patrol (SMP).
  - Reporting quality-of-care complaints to the BFCC-QIO (visit www.qioprogram.org to find your BFCC-QIO).