Getting a fast appeal in a hospital

If you’re getting Medicare services from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice, and you think your Medicare‑covered services are ending too soon (or that you’re being discharged too soon), you can ask for a fast appeal. Your provider will give you a notice before your services end telling you how to ask for a fast appeal. The notice might call it an “immediate appeal” or an “expedited appeal.” You should read this notice carefully. If you don’t get this notice, ask your provider for it. With a fast appeal, an independent reviewer will decide if your covered services should continue.

You can contact your Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) for help with filing an appeal. A fast appeal only covers the decision to end services. You may need to start a separate appeals process for any items or services you may have received after the decision to end services. For more information, view the booklet Medicare Appeals

You may be able to stay in the hospital (

Coinsurance

 and 

Deductible [glossary]

 may apply) while the BFCC-QIO reviews your case. The hospital can't force you to leave before the BFCC-QIO reaches a decision.

Within 2 days of your admission and prior to your discharge, you should get a notice called "An Important Message from Medicare about Your Rights." This notice is sometimes called the Important Message from Medicare or the IM. If you don't get this notice, ask for it. This notice lists the BFCC-QIO's contact information and explains:

  • Your right to get all Medically necessary hospital services
  • Your right to be involved in any decisions that the hospital, your doctor, or anyone else makes about your hospital services and to know who will pay for them
  • Your right to get the services you need after you leave the hospital
  • Your right to appeal a discharge decision and the steps for appealing the decision
  • The circumstances under which you will or won’t have to pay for charges for continuing to stay in the hospital
  • Information on your right to get a detailed notice about why your covered services are ending

If the hospital gives you the IM more than 2 days before your discharge day, it must give you a copy of your original, signed IM or provide you with a new one (that you must sign) before you're discharged.

How do I ask for a fast appeal?

You may have the right to ask the BFCC-QIO for a fast appeal. Follow the directions on the IM to request a fast appeal if you think your Medicare-covered hospital services are ending too soon. You must ask for a fast appeal no later than the day you're scheduled to be discharged from the hospital.

If you ask for your appeal within this time frame, you can stay in the hospital while you wait to get the BFCC-QIO's decision. You won't have to pay for your stay (except for applicable coinsurance or deductibles).

If you miss the deadline for a fast appeal, you can still ask the BFCC-QIO to review your case, but different rules and time frames apply and you might be responsible for the cost of the hospital stay past the original day the hospital tries to discharge you. If you're in a Medicare Advantage Plan, you can ask your plan for an appeal, but different rules apply.

What will happen during the BFCC-QIO's review?

When the BFCC-QIO gets your request within the fast appeal time frame, it will notify the plan and the hospital. Once your plan and the hospital are notified by the BFCC-QIO, your plan or the hospital will provide you a "Detailed Notice of Discharge." Your plan or the hospital will provide this notice by noon of the day after the BFCC-QIO notifies the hospital. The notice will include:

  • Why your services are no longer reasonable and necessary or are no longer covered
  • A description of the applicable Medicare coverage rule or policy, including information on how you can get a copy of the policy
  • How the applicable coverage rule or policy applies to your specific situation

You can also ask your plan for copies of any of the materials that your plan sent to the BFCC-QIO about your hospital discharge. The BFCC-QIO will look at your medical information provided by the hospital and will also ask you for your opinion. The BFCC-QIO will decide if you're ready to be discharged within one day of getting the requested information.

If the BFCC-QIO decides that you're being discharged too soon:

Medicare will continue to cover your hospital stay as long as medically necessary (except for applicable coinsurance or deductibles) if your plan previously authorized coverage of the inpatient admission, or the inpatient admission was for emergency or urgently needed care.

You may need to appeal the denial of coverage for your plan to pay if your plan never authorized the inpatient admission, or the inpatient admission wasn’t for emergency or urgently needed care.

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 the hospital charges (except for applicable coinsurance or deductibles) incurred through noon of the day after the BFCC-QIO gives you its decision. If you get any inpatient hospital services after noon of that day, you may have to pay for them.

Additional Resources Related to Discharge Appeal:

The Beneficiary Care Management Program (BCMP) is a CMS Person and Family Engagement initiative supporting Medicare Fee-for-Service beneficiaries undergoing a discharge appeal, who are experiencing chronic medical conditions requiring lifelong care management. It serves as an enhancement to the existing beneficiary appeals process. This program is not only a resource for Medicare beneficiaries, but extends support for their family members, caregivers and providers as active participants in the provision of health care delivery.

The BCMP program will focus on these key care management support services: 
                                      

  • Discharge Planning and Care Coordination
  • Healthcare Care Navigation, and
  • Beneficiary Empowerment and Self Care


The BCMP program is a referral-based program, initiated by your respective Regional BFCC-QIO. If you or a family member have an active discharge appeal, we encourage you to contact the Regional BFCC-QIO to discuss if you could benefit from this service. At your convenience, you may also access additional program information at: https://www.bcmpqio.org.