Starting July 1, 2007, hospitals participating in the traditional or Medicare
Advantage Medicare program must provide beneficiaries with a new notice of
discharge and appeal rights, as discussed in last week’s Weekly Alert.
This Weekly Alert describes the new notice as well as beneficiary rights
to question and appeal hospital discharge decisions and to receive continued
The new notice, known as An Important Message from Medicare about Your Rights
(IM) can be found at
The requirements for the new notice are discussed in Guidelines which were
released by the Centers for Medicare and Medicaid Services (CMS) on May 25,
2007. In the Guidance, CMS explains when and how Medicare patients must be given
information about their discharge and appeal rights. The Guidance is part of the
CMS Medicare manual system,
and can be accessed at
Starting July 1, the IM must be given, in most cases, at least twice during a
Medicare patient’s hospital stay. First, upon admission, Medicare
beneficiaries must receive the initial IM which they are to read, sign and date.
The IM is to inform the beneficiaries of the process available to challenge a
hospital’s discharge decision. The CMS guidance document describes the events
that trigger a hospital’s duty to provide beneficiaries with an additional,
follow-up IM notice. At or near the point of discharge, beneficiaries are to
receive this second notice. The exception to the two-notice requirement is an
individual who is in the hospital for just 3 days. One IM can be given on
day 2, and suffice as both the initial and discharge IM.
Upon receipt of a hospital’s discharge decision, beneficiaries may appeal the
decision by requesting a timely review by the appropriate Quality Improvement
Organization (QIO). When QIO review is requested, an additional notice called
the Detailed Notice of Discharge (Detailed Notice) is to be given. The Detailed
Notice is to explain the medical basis for the discharge decision. CMS has
issued a Question & Answer document elaborating on the use of IM and the
Detailed Notice. This CMS Q & A document can be found at:
What Basic Information Must the “IM” Contain?
The IM must contain the following essential pieces of information:
The name(s) of
the patient’s physician(s) and the patient’s ID number.
A statement of
the right to file an appeal or raise questions with a QIO about quality of
care, including hospital discharge.
The name and
telephone number of the QIO that serves the area in which the hospital in
question is located.
A space for the
beneficiary or representative to sign and date the document.
necessary to appeal a hospital discharge decision or to file a complaint
about the quality of care.
What Basic Information Must the “Detailed Notice” Contain?
The Detailed Notice must contain the following essential pieces of
The name(s) of
the patient’s physician(s) and the patient’s ID number.
The date the
Notice was issued.
The date the
inpatient hospital services are to end.
A statement that
the Detailed Notice is not an official Medicare decision.
information about the patient’s current medical condition.
and/or Medicare plan telephone number for requesting copies of documents to
be sent to the QIO.
When Must the “IM” be Distributed?
The patient must receive the original IM within two days of admittance to the
hospital. The hospital must obtain the signature of the beneficiary or of his or
her representative and provide a copy to that person at that time. If the
patient or representative refuses to sign the IM, then the hospital is required
to make a note to that effect; for purposes of requesting an appeal, the date of
the refusal to sign is considered the date of notification. A follow-up copy of
the signed IM should again be given “as far in advance of the discharge as
possible, but not more than 2 calendar days before discharge.” If discharge
occurs within 2 days of the date the IM was given, no follow-up copy is
A beneficiary may be considered discharged when Medicare decides it will no
longer pay for the medical services or when the physician and hospital believe
that medical services are no longer required. The Medicare Claims Manual
provides that a patient may be considered to have been discharged when s/he is
either physically required to leave the hospital (not merely transferred to
another inpatient setting) or when s/he remains in the hospital but at a lower
level of care.
Discharge Decision Concerns
Notification of the beneficiary’s discharge and appeal rights should not be
hindered when the hospital cannot anticipate the date of discharge. According to
CMS, if hospitals cannot anticipate the discharge date, the follow-up IM notice
may be given on the day of discharge, at least four hours in advance of the
Beyond requiring that the follow-up IM be given at a minimum of four hours in
advance of discharge, CMS does not require the hospital to again obtain the
patient’s signature when this follow-up IM is given. The hospital may simply
distribute a copy of the signed and dated IM that was given at admission.
However, hospitals are not precluded from obtaining a new IM and verifying
signature from the beneficiary. By allowing this practice, CMS has made it
possible for hospitals to eliminate the need for a follow-up copy of the IM
during inpatient stays of up to 5 days. This lack of timely notice may hinder
the ability of Medicare patients to be fully aware of and exercise their appeal
Appeals of Hospital Discharge
As previously discussed, when a hospital (with physician concurrence) determines
that inpatient care is no longer necessary, the Medicare beneficiary has the
right to request an expedited QIO review. The CMS guidelines provide that the
appeal for expedited review must be made before the beneficiary leaves the
hospital. Therefore, the beneficiary should not be discharged upon requesting
the QIO review.
In order for the review request to be considered “timely”, beneficiaries must
submit their requests in writing or by telephone no later than midnight of the
day of discharge and before they leave the hospital. The beneficiary, therefore,
should not be discharged upon requesting the QIO review, so long as the request
is made on the same day.
The beneficiary or qualified representative should be contacted by the QIO to
discuss the case with the QIO and provide any necessary information that may be
required. The hospital is required to submit all pertinent information to the
QIO. The patient or his or her representative also has the ability to obtain the
same information from the hospital and/or QIO. In addition, the QIO should
obtain medical records from the hospital, including speaking to the patient’s
physician(s). A timely request will trigger the QIO to render a decision within
1 calendar day after receiving all of the necessary information.
The Detailed Notice of discharge must be delivered “as soon as possible”
after the beneficiary has requested a QIO review, but no later than noon of the
day after the QIO notifies the hospital of the beneficiary’s request for the
review. Under the CMS guidelines, hospitals are only required to deliver the
Detailed Notice after the beneficiary has contacted the QIO for expedited
review or when the beneficiary requests more detailed information from the
medical care provider prior to requesting a QIO review.
The Detailed Notice is not an official Medicare decision. It is designed
to give the patient further explanation about why the hospital and/or physician
believe that the medical services are no longer necessary.
Beneficiaries are not financially liable for hospital costs incurred during a
timely QIO review; they are responsible only for coinsurance and deductibles.
Further, the burden of proof lies with the hospital to demonstrate that the
discharge is the correct decision based on either medical necessity or other
Medicare coverage policies. If the QIO decision is in agreement with the
hospital (unfavorable to the patient), then the beneficiary becomes liable for
the medical expenses incurred beginning at noon on the day after
notification of the decision is given.
Medicare beneficiaries have the right to question the hospital’s and physician’s
decision to discharge them from care; however the CMS Guidance on this subject
continues to raise concerns. The Guidance lacks any requirement that hospitals
obtain a signature from beneficiaries or their representatives attesting to
their comprehension of the delivery of the follow-up IM. That follow-up
acknowledgment is crucial, however, because the most important time for
beneficiaries to understand their rights is before discharge. Notices are
useless if they are delivered to patients who are being wheeled out the door.
This deficiency also weakens CMS’s ability to monitor when the notices are
delivered and to ensure that they are being provided in a timely and responsible
 Pub 100-04, Transmittal 1257, Change Request 5622
 If the beneficiary fails to request an expedited QIO review,
s/he may still request one within 30 calendar days after receipt of the
discharge notice or at any time for good cause. If the beneficiary stays
in the hospital during this time, s/he will be liable for the charges
incurred after the scheduled day of discharge unless the QIO review
finds that discharge was inappropriate, thus agreeing with the