Dear Marci,
I have been recovering from surgery at a skilled nursing facility (SNF), but recently was told I am being discharged this week. How can I appeal my discharge from a SNF?
– Matthew (Rochester, NY)
Dear Matthew,
If you are receiving care in a non-hospital setting and are told that Medicare will no longer pay for your care (and you will be discharged), you have the right to file a fast appeal if you do not believe your care should end. Non-hospital settings include skilled nursing facilities, Comprehensive Outpatient Rehabilitation Facilities (CORFs), hospice, or home health agencies.
If your care at a non-hospital setting is ending because your provider believes Medicare will not pay for it, you should receive a Notice of Medicare Non-Coverage. You should get this notice no later than two days before your care is set to end. If you receive home health care, you should receive the notice on your second to last care visit. If you have reached the limit in your care or do not qualify for care, you do not receive this notice and you cannot appeal.
If you feel that your care in a non-hospital setting should continue, follow the instructions on the Notice of Medicare Non-Coverage to file an expedited appeal with the Quality Improvement Organization (QIO) by noon of the day before your care is set to end. Once you file the appeal, your provider should give you a Detailed Explanation of Non-Coverage. This notice explains in writing why your care is ending and lists any Medicare coverage rules related to your case.
The QIO will usually call you to get your opinion. You can also send a written statement. If you receive home health or CORF care, you must get a written statement from a physician who confirms that your care should continue.
If you have Original Medicare, the 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 QIO should make a decision no later than the day your care is set to end. Your provider cannot bill you before the QIO makes its decision. If the QIO appeal is successful, you should continue to receive Medicare-covered care, as long as your doctor continues to certify it.
If your appeal is denied at this first level, you can continue to appeal by following instructions on the denial notices you receive. There are five levels of appeal in total; the timing and agency involved depend on whether you have Original Medicare or a Medicare Advantage Plan. You have the right to continue appealing if you are not successful.
Expedited appeals have tight deadlines, so it is important to pay attention to the timeframes for appealing at each level. Keep copies of any appeal paperwork you send out, and if you speak to someone on the phone, get their name and write down the date and time that you spoke to them. It is helpful to have all of your appeal documents together in case you run into any problems and need to access documents you already mailed.
Note that the appeal process is different if your inpatient hospital care is ending or if your care is being reduced but not ending, and you do not agree with that reduction.
– Marci