Dear Marci,
 
I am recovering from a surgery in a skilled nursing facility (SNF). I was told a date for my discharge, which was earlier than I felt ready to go home, so I appealed. I just found out my appeal was denied. Is there anything else I can do?
 
-Lindiwe (Severna Park, MD)
 
Dear Lindiwe,
 
You have the right to further appeals after an initial denial of your appeal by the Quality Improvement Organization (QIO). Since your appeal was denied by the QIO, remember that you may be responsible for the cost of any care you receive after the end date on your Notice of Medicare Non-Coverage if you do not win your appeal.
 
What to do next will depend on whether you have Original Medicare or a Medicare Advantage Plan, but remember that at every step in the appeals process, it is important to read notices thoroughly and follow all instructions and deadlines.
 
If you have Original Medicare, your next step is to appeal to the Qualified Independent Contractor (QIC). The instructions for where to send this appeal should appear on the notice you received from the QIO. To continue the expedited appeals process, you should appeal to the QIC by noon of the day following the QIO’s decision. The QIC will make a decision within 72 hours. Your skilled nursing facility cannot bill you for continuing care until the QIC makes a decision. However, if you are denied by the QIC, you will be responsible for paying all the costs of your care out-of-pocket, including costs incurred during the 72 hours when the QIC was making its decision.
 
If you have a Medicare Advantage Plan, your next step will be to appeal to the QIO again. You should file this second appeal within 60 days of the QIO’s initial denial. A different set of staff will reconsider your appeal. They should make a decision within 14 days of getting the appeal. If you continue to stay in the nursing facility, they will not be able to bill you until the QIO makes its decision. However, if you lose your appeal, you will be responsible for all costs, including costs from the time when the QIO was making its decision. 
 
If you win in your second appeal, your continued care in the nursing facility will be covered by Original Medicare or your Medicare Advantage Plan. If you are not successful, you can still appeal further. You may want to consider seeking assistance from a lawyer or legal services organization at this point, although you do not need to have legal representation. The steps for further appeals will be the same whether you have Original Medicare or a Medicare Advantage Plan:
 

• You can request a hearing with the Office of Medicare Hearings and Appeals (OMHA). The bill for care that is not covered must be at least $160 in 2017 to be able to use this level of appeal. This is called the amount in controversy, and it may change from year to year. You should file your appeal within 60 days of the date on your denial letter from the QIC (if you have Original Medicare) or QIO (If you have a Medicare Advantage Plan). OMHA should make a decision within 90 days.
• If OMHA denies your appeal, you can appeal to the Council within 60 days of the date on your denial. There is no timeline for the Council to make its decision.
• If the Council denies your appeal, you can appeal in Federal District Court. To file a case in Federal District Court, you must have an amount in controversy of at least $1,560 in 2017. You should appeal to the Federal District Court within 60 days of the date on your denial letter from the Council. Most people who file a claim in Federal District Court have an attorney help them. There is no timeframe for the Federal District Court to make a decision.

 
If you have not already, you should ask your physician if they can support your appeal with a letter of medical necessity that addresses the reasons you continue to need care in a skilled nursing facility. Also, remember that a family member or other representative can appeal for you if you are too ill or otherwise unable to appeal on your own. If you have questions about the appeals process, you can call your Medicare Advantage Plan or 1-800-MEDICARE, or you can seek help from your State Health Insurance Assistance Program (SHIP) by visiting www.shiptacenter.org or calling 877-839-2675.
 
-Marci

Dear Marci,

My mother has Original Medicare and is currently receiving care from a skilled nursing facility. Her provider gave her a notice saying that she will be discharged soon, but she does not feel she is ready to go home. Is there any way she can stay in the skilled nursing facility and get Medicare to cover the stay?

– Judy (Rockford, IL)

Dear Judy,

Yes, your mother can appeal to Medicare to request that herskilled nursing facility stay and coverage continue. The notice her provider gave her was a Notice of Medicare Non-Coverage, which contains information about how your mother should begin her appeal. This appeal is expedited, meaning that you will quickly know whether the appeal is accepted or denied.

Your mother can start her appeal by contacting the Beneficiary and Family Centered Care – Quality Improvement Organization (BFCC-QIO or QIO for short) by, at the latest, noon of the day before her care is set to end. It is best to contact the QIO as soon as possible.

Next, the QIO will alert your mother’s provider of the appeal and collect the information it needs to review the case. Once the provider learns about the appeal, they should give your mother a Detailed Explanation of Non-Coverage that explains why the care is ending. This notice will also list any Medicare coverage rules related to her case. Your mother should receive this notice within the same day that her provider learns about the appeal from the QIO.

In addition to information supplied by the provider for your mother’s appeal, you and she can submit your own evidence to support her need for continued SNF care—but this is not required.

After submitting evidence, your mother may speak with the QIO on the phone again or submit a written statement about why her care should continue. The QIO will decide if Medicare will continue to cover care based on the information it receives from the SNF and your mother. The QIO must give your mother a decision no later than two days after her Notice of Medicare Non-Coverage says her care is set to end. This decision can be made by telephone but must also be sent in writing.

If the QIO decides that your mother’s care should continue, she should continue to receive care as long as her provider continues to certify it.

If the QIO decides that your mother’s care should not continue, your mother can choose to move on to the next level of appeal.

Throughout the appeal process, it is important to keep copies of all documents, write down the names of people you speak to on the phone, and send appeal paperwork through certified mail. Good luck!

– Marci