Humana's Your Practice

Hospital Discharge Rights

A Medicare beneficiary who is an inpatient must be notified of his or her right to request an immediate review of his or her planned discharge from the hospital’s affiliated Quality Improvement Organization (QIO). On July 2, 2007, the Centers for Medicare & Medicaid Services (CMS) issued a final rule concerning the responsibilities of hospitals, Medicare Advantage (MA) health plans and provider groups delegated for inpatient utilization management in these situations.

Complete information about the CMS final rule is available at http://www.cms.hhs.gov/BNI/05_HINNs.asp. The information below summarizes key points of the rule.

Hospital responsibilities:

Admission. When an MA beneficiary is admitted to a hospital, he or she must be provided with an “Important Message” (IM) notice outlining his or her rights within two days of admission. The notice must be provided by the hospital and include the following:

Right to benefits for inpatient services and post-hospital services;
Right to request immediate review of the discharge decision and the availability of other appeals processes if the beneficiary does not meet the deadline for immediate review;
Liability for charges for continued stay; and
Right to receive additional information.

The notice must be delivered to the beneficiary in person and the beneficiary must sign the notice. If the beneficiary is unable to comprehend and/or sign, the notice must be delivered to and signed by the beneficiary’s representative. If the beneficiary or representative refuses to sign the notice, the hospital may note the refusal on the form.

Discharge. A copy of the signed IM notice must be delivered to the beneficiary or the beneficiary’s representative no more than two days before discharge. (If the patient’s inpatient stay has been two calendar days or less, the follow-up copy is unnecessary.) The beneficiary’s inpatient physician must concur with the discharge decision and document concurrence with the discharge plan in the progress notes. A discharge order should also be present upon discharge.

When notified of a QIO review. The hospital must furnish all requested information by the close of business the same day that the notification is received.

MA Plans’ responsibilities: When the plan is notified of the beneficiary’s request for a QIO review, the plan must deliver the Detailed Notice of Discharge (form CMS-10066) to the beneficiary no later than noon of the following day. The notice must cover:

Why services are no longer covered;
Applicable Medicare coverage rule or policy and how the beneficiary may obtain a copy from the plan;
Applicable plan policy on which discharge determination was based; and
Facts specific to the beneficiary.

The plan must supply the QIO with all information related to the current inpatient stay and all notices delivered to the beneficiary by noon of the day following notification of the QIO review.

QIO responsibilities:

The QIO must notify the hospital and the MA plan upon receipt of the request.
The QIO must make a determination and notify the beneficiary, the MA plan, the attending physician of record and the hospital within one calendar day of receiving all requested information.

Beneficiary responsibilities:

A beneficiary may request an immediate review of his or her discharge to the QIO. In order for a request for QIO review to be considered timely, it must be made before the beneficiary leaves the hospital and no later than midnight on the day of discharge. Review requests made outside these parameters will be considered untimely (see below).
Requests may be made in writing or by telephone. The beneficiary or the beneficiary’s representative must be available to discuss the case.
If the review upholds the discharge decision, the beneficiary has 60 days to request that the QIO reconsider the decision. If the beneficiary is no longer an inpatient at the hospital and is dissatisfied with the QIO decision, the beneficiary may appeal directly to an administrative law judge, the Medicare Appeals Council or a federal court.
Untimely requests for review must file an appeal through Humana’s grievance and appeals department and follow department procedures.