How to Fight a Hospital Discharge
Fact checked by Marley Hall
If you have been hospitalized and feel that you're being released too early, there are steps you can take to start appealing a discharge from the hospital. With that said, it can sometimes be challenging as you will need to provide a rationale to your insurance provider and may even need to fight the hospital to stay. If your appeal is denied, you may be forced to pay out of pocket.
This article offers reasons why you may need to stay in the hospital and ways to work with your healthcare provider to obtain approval. It also walks you through what is involved in filing an appeal and ways to fight the hospital if they want you to leave.
How the Length of a Hospitalization Is Determined
Before you are admitted to the hospital, the hospitalization and any predicted tests, procedures, and treatments must be approved by your payer—such as an insurance company or a public payer like Medicare, Medicaid, Tricare, or the Veteran's Administration (VA).
To determine what they will cover, payers rely on diagnostic codes called ICD codes and procedure codes called CPT codes that describe what is needed to treat a diagnosed condition. Included in the descriptions are the average amount of time you will need to be in the hospital to complete the tasks that fall under those codes.
The definition of "average” is based on what a patient with no additional medical issues requires to be appropriately treated. It is not based on an individual's health status or their physical readiness to leave.
Based on the codes assigned to you, the payer is obligated to pay that amount and no more. As such, if you are hospitalized and your time is up, your payer will no longer pay for your stay. Unless you pay cash or get authorization for an extension, the hospital will need to send you home.
Reasons You May Need to Stay Longer
Problems arise if you aren’t the “average” patient and are not ready to be discharged. Among the reasons you may need to stay longer:
You are not healing from surgery as expected.
You’ve acquired a hospital infection or other complications of surgery.
There has been a drug error, drug reaction, or complications from anesthesia.
You are older or frail and cannot be transferred to your home safely.
You need to be transferred to a skilled nursing center or rehab, but Medicare won’t pay unless you’ve been hospitalized for at least three days.
The initial diagnostic code was incorrect and you require more care than was indicated.
In such cases, your healthcare provider can contact your insurance provider and provide what they need to approve the extension and any other treatments you need.
In some cases, the hospital will determine this on its own (such as if a postoperative complication occurs) and gain approval from your insurance provider without you even knowing it.
Reasons You May Be Denied
It’s also possible your reluctance to leave isn’t based on your health status at all; rather it's about the lack of caregiving support you have at home or the fear that something major could happen and go unnoticed without 24/7 monitoring.
Or, maybe you are just lonely and appreciate the attention you get in the hospital. The truth is, in most cases, these are not good enough reasons to stay.
In such cases, you can work with your healthcare provider to determine if there is coverage for a home health worker, home-based nursing care, a rehabilitation facility, or short-term nursing home care to address these needs.
How to Appeal a Discharge
Once you’ve been given a discharge date and you and your healthcare provider agree that you should extend your stay, you will need to file an appeal with your insurance provider.
The steps for an appeal will vary from hospital to hospital and from state to state. (The only exception is Meidicare which has a specific process to follow no matter where you live or what hospital you’ve been admitted to.)
To start the appeals process:
Review the hospital policies: Your hospital admission papers include a statement of your rights along with discharge information and how to appeal a discharge. If you aren’t provided this, request one from the hospital's patient advocate.
Speak with the QIO: The hospital staff member tasked with appeals is the Quality Information Officer (QIO). The federal government has strict requirements about how QIO handles discharge appeals. Once the appeal is submitted, expect to receive a decision within 24 hours.
Know your rights: In most instances, you can appeal on the day of discharge and stay in the hospital without financial liability until noon of the day after the hospital has received QIO notification. The hospital can't force you to leave before a decision is reached.
Work with your healthcare provider: Your surgeon or the healthcare provider can submit the necessary documentation warranting that an extended hospital stay is a medical necessity.
Ask about the "Safe Discharge" policy: Safe discharge means that a patient has appropriate care and support in place once they are discharged. There are strict definitions for determining if a discharge is safe, which can presented to your insurance provider.
Related: How Medicaid Prevents Hospital Readmissions
How to Fight the Hospital
When fighting an early hospital discharge, your insurer may not be your only concern. There may be instances where the hospital will insist that an extension is unnecessary.
The hospital may have a genuine medical reason for this or be simply running short of beds. Or, there may be a medical emergency, such as an infectious outbreak or a natural disaster, in which they have to prioritize certain patients over others.
Whatever the situation, you may be forced to fight the hospital administrator. One way to do so is with the hospital's "Safe Discharge" policy. Particularly with respect to Medicare, hospitals that release patients too early can be financially penalized if the patient is readmitted soon after.
According to the Hospital Readmission and Reduction Program (HRRP) enacted under the Affordable Care Act, a hospital can be penalized if there are excessive readmissions of Medicaid patients. This is defined as readmissions to their or any other hospital or emergency room within 30 days of a discharge.
To date, the HRPP ruling applies to only the following medical conditions, although more are being proposed:
Acute mocardial infarction (heart attack)
Elective primary total hip arthroplasty (hip replacement)
Elective primary total knee arthroplasty (knee replacement)
While the same directive does not apply to non-Medicare patients, it does not mean that you have to give up if the hospital wants you to leave. There are things can you do either on your own or with a patient advocate to overturn the decision:
Ask why you are being discharged when how your condition has not improved. Give examples. Sometimes, talking face-to-face with a healthcare provider or hospital administration can highlight the gravity of your situation.
Request a second opinion or an in-hospital consultation with the appropriate specialist.
Remind the nursing staff of their duty to advocate for your care. Get the nursing supervisor involved if needed.
Read Next: Can a Hospital Force You to Stay?
Summary
If you feel you are being discharged from the hospital too soon, you have the right to appeal.
Although there are different appeals processes, you would ultimately need a healthcare provider to explain why an extended stay is a medical necessity. A Quality Information Officer or a similar hospital staff member would submit the request to your insurer, the reply of which should be received within 24 hours.
You can file the appeal on the day of your discharge and will generally not be financially responsible for any additional charges until noon of the next day. After that, you may be responsible if you decide to stay and the appeal is denied.
Read the original article on Verywell Health.
