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If you are enrolled in a Medicare Advantage plan or Medicare health plan, you can ask for a fast appeal if you’re receiving Medicare services from a facility or health-care agency and you think your Medicare-covered services are ending too soon.
Your right to a fast appeal exists when a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility (CORF), or hospice agency notifies you that its services to you will be discontinued.
How will I know I need to ask for a fast appeal?
If you’re in the hospital, you should receive a notice from the hospital called “An Important Message from Medicare about Your Rights.” You should get this notice within two days of being admitted and before you’re discharged from the hospital, so make sure to ask for it if you haven’t received it. This notice explains your rights:
- To get all medically necessary hospital services, both during your stay and when you leave the hospital;
- To be involved in any decisions that the hospital, your doctor, or anyone else makes about your hospital care and who will pay for it;
- To get a notice that your Medicare covered services are ending;
- To receive information about why your Medicare covered services are ending;
- To know the circumstances under which you will or won’t have to pay for services if you continue to stay in the hospital; and
- To a fast appeal and information on how to contact the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) in your state to request one.
The hospital will ask you to read the notice, sign it, and date it. If you get this notice more than two days before the day you’re discharged, the hospital should give you another copy of the notice that you’ll also need to sign or provide you with a copy of your signed, original notice. Remember, if you don’t get the notice, ask for it.
If you’re getting care from a skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice agency, you should receive a notice similar to the one described above, called a “Notice of Medicare Non-Coverage” at least two days before covered services end. This notice contains the same important information about your right to appeal the decision to discontinue services and instructions on how to do so.
When do I request a fast appeal?
Once you receive a discontinuation of services or discharge notice, you should immediately contact your local Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) to appeal if you disagree with the decision. The BFCC-QIO is a group of doctors and other health-care professionals who monitor the quality of care delivered to Medicare beneficiaries. They are paid by the federal government and not affiliated with a provider or Medicare plan. The phone number should be on the notice you received.
It is very important to contact the BFCC-QIO right away. You must contact them no later than the date noted on your discontinuation of services notice. This deadline varies depending on if you’re staying in a hospital setting or getting care through another type of facility, such as a skilled nursing facility or comprehensive outpatient rehabilitative facility.
If you’re staying in a hospital, you must request an appeal no later than the day you’re scheduled to be discharged; if you’re staying in a facility other than a hospital, this is typically no later than noon of the first day after you get the “Notice of Medicare Non-Coverage.” If you do this, you may not have to pay for your Medicare-covered care while you wait for your appeal review decision (aside from any coinsurance or deductibles that may apply). If you miss the deadline for a fast appeal, the hospital or facility can begin charging you.
What happens during the fast appeal review?
The BFCC-QIO will conduct a review of the discontinuation of services based on the information they get from the hospital or facility providing your services and decide if the coverage should continue. The BFCC-QIO may ask you to provide supporting medical information about your condition and why you think services should be continued. You can ask your doctor to send information to support your appeal. The BFCC-QIO doctors will review the medical necessity, appropriateness, and the quality of treatment given to you. The facility or agency providing your care cannot discharge or discontinue its services while the BFCC-QIO is reviewing the discontinuation of services decision.
Do I have to pay for the services I receive?
You won’t be responsible for paying charges for Medicare-covered services you receive during the BFCC-QIO appeal review if you request a fast appeal by the deadline (except any deductible and/or coinsurance amounts that may apply to your Medicare plan).
If the BFCC-QIO decides that you’re ready to be discharged and you met the deadline for requesting a fast appeal, you won’t be responsible for paying for covered hospital services you receive through noon of the day after the BFCC-QIO gives you its decision (except any applicable deductible and coinsurance amount). If you get inpatient hospital services after noon of that day, you may have to pay for them.
If you’re getting care through hospice care, a skilled nursing facility, a home health agency, or a comprehensive outpatient rehabilitative facility and you’ve submitted the fast appeal request by the deadline, you won’t be responsible for paying for services you received before the termination date on your “Note of Medicare Non-Coverage.” However, if you get further services after the end-date on this notice, you may be responsible for paying for those costs.
If the BFCC-QIO agrees with you that your services are being discontinued too soon, your Medicare plan will continue to cover your services in the hospital or other care setting as long as medically necessary. You may have to pay an applicable deductible or coinsurance amount.
Do you have any other questions about the Medicare fast appeal process? I’d be happy to help you if you want to learn more about your Medicare coverage and options.
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