Medicare FAQs

Hospitals — What should you know
when your loved one is a Medicare patient?

If you're looking for assisted living, home health care, skilled nursing or a nursing home, it's usually because of a medical crisis involving a loved one. You're probably in a time crunch — decisions have to be made quickly. The hospital may have said that your loved one will be discharged tomorrow. They've given you a list of rehab facilities, and it's up to you to pick one. But, how do you know which one is best? Are some better than others?

If you're in this situation — take a deep breath — relax a little — and read the next paragraph. You might make a better decision as a result.

Medicare has special rules to keep patients from being discharged from the hospital too soon. In spite of what they may have said, your loved one cannot be discharged until 3 days after the hospital gives you a form called a Notice of Noncoverage. If they have not given you the Notice, insist that they do. (You won't get into trouble by insisting, and neither will your loved one.) This will give you additional time to find the rehab facility that's best for your loved one.

Hospitals discharge Medicare patients quicker and sicker than ever before. In 1968, patients age 65 and older stayed in the hospital an average of 14.2 days. By 1982, that was down to 10.1 days. Now it only 6.4 days.

Why? Medicare is under constant pressure from Congress to cut expenses. Now, Medicare benefits pay a hospital the same fixed fee for each patient with a particular medical condition — even if one patient's condition is more severe than another's. If a patient stays too long, the hospital has to pay the extra costs out of its own pocket. But, the shorter a patient stays, the more money the hospital gets to keep.

How bad has the situation become? According to The Wall Street Journal, "Nearly one in five people admitted to hospitals with broken hips are discharged before all of their vital signs are stable — . Those patients are far more likely to die or be readmitted to the hospital within two months."

To protect you, Medicare guarantees you certain rights if you think you are being asked to leave the hospital too soon. Unfortunately, these rights are given to you along with all the other papers a hospital makes you sign when you are admitted. So, they are usually lost in the shuffle, with most people never realizing how important they are. Hospitals sometimes take advantage of that fact (see the Personal Note from our President at the bottom of this page).

Your rights are described in the form, "An Important Message From Medicare -- Your Rights While You Are A Medicare Hospital Patient." That form must be given to you when you are admitted. Here's a summary of what it says for most hospitals.

If your doctor or hospital tells you that you are going to be discharged, and you think it is too soon, you have 3 options:

Option #1 — Immediately ask a representative of the hospital for a written explanation, if you have not already received one. It is called a "Notice of Noncoverage." This notice will tell you if your doctor or your hospital's Peer Review Organization (PRO) agrees with your hospital's decision to discharge you.

You should be given the Notice at least 3 calendar days before your discharge date. Even if you decide not to appeal your hospital's decision, your hospital cannot charge you (you pay nothing) for the cost of your stay during those 3 days. If your hospital has not given you the Notice, the 3-day clock does not begin until they do.

Tip: This is especially important if the hospital wants to send you to a rehab facility to continue your recovery (most rehab facilities are skilled nursing facilities / nursing homes, not assisted living facilities). You don't have to go the facility where the hospital wants to send you; instead, use these 3 days to find the best one that's certified by Medicare.

If you don't, and you later move into another rehab facility, Medicare won't cover you there, even if the second one gives you a better chance for full recovery. Instead, you'll have to pay the entire cost of your stay in the second facility out of your own pocket.

Option #2 — If you decide to appeal and your doctor agrees with your hospital. You must ask the hospital's PRO to review the discharge decision. You can contact the PRO in writing or by phone. (The Notice includes the PRO's address and telephone number.) But, you must make your request before noon of the first work day after you receive the Notice.

If the PRO agrees with the Notice, you may be billed for the costs of your hospital care incurred beginning from noon of the day after you receive the PRO's decision. You will not be charged for your hospital care from the time you make your request until you receive the PRO's decision that it agrees with the hospital. Of course, if the PRO disagrees with your hospital, Medicare will continue to pay for your hospital care.

Option #3 — If your doctor disagrees with your hospital. Your hospital may ask the PRO to review your case. If the PRO agrees with your hospital, and you still feel that you are being discharged too soon, your can ask the PRO to reconsider their decision. Your request must be made by phone or in writing to the PRO immediately as soon as you receive the Notice.

The PRO can take up to 3 working days to complete their review. It will inform you in writing of its decision. But, remember that in this example, the PRO has already reviewed your case once (before the Notice was issued).

As a result, your hospital is allowed to begin billing you for your care beginning with the 3rd calendar day after you receive the Notice, even if the PRO has not completed its review. If the PRO continues to agree with your hospital, you may have to pay for at least one day of hospital care.

Now that you know your rights, it's important to stand up for them. Many people, especially seniors, are afraid they might anger hospital staffers or their doctors, so they don't ask questions or complain, even when they aren't being treated right. Remember, you have the right to be fully informed, to be involved in the decision-making process regarding your health care, and to receive all the hospital care necessary for the proper treatment of your illness or injury.

To see the entire Important Message from Medicare, click here.

A Personal Note from our President

Hospitals don't always follow Medicare's rules, especially if they can save money by ignoring them. Our family experienced this twice with hospitals in Florida and Indiana.

My mother, after being virtually comatose in intensive care for 15 days, suddenly improved, and was discharged the next day. She was never given a Notice of Noncoverage. Thus, the hospital saved the cost of the 3 additional days of care she was entitled to stay at no charge.

My wife's mother, very weak from a variety of ailments, was admitted on a Friday for emergency surgery for a blocked intestine. She was sent home the following Monday (3 days later), never being given a Notice of Noncoverage. Once again, the hospital saved the cost of the 3 additional days of care she was entitled to, at no charge.

Why did they discharge our mothers so quickly — and ignore Medicare's rules? Hospitals don't have a 3-day rule for younger patients who are not on Medicare; they discharge those patients whenever they want to. If I were cynical, I'd say that hospitals take advantage of older patients who want to go home as soon as possible, even if it is not in their best interest, just to save a few dollars. But, I prefer to believe that hospital administrators simply don't realize that different rules apply to Medicare patients, or they haven't adequately trained their staffs.

Remember — it is important to know your rights and stand up for them in order to receive all the hospital care you need and are entitled to.