How to Appeal a Medicare Discharge Decision

If your hospital or skilled nursing facility is telling you that Medicare will no longer cover your stay and you must be discharged — even though you believe you still need care — you have the right to an immediate, urgent appeal. Federal law gives you specific protections that can keep your coverage active while your case is reviewed. Acting quickly is essential.

Your Core Right: Benefits Continue During Appeal

This is the most important thing to know: if you appeal before your Medicare coverage ends, your benefits continue during the review period at no additional cost to you (beyond your normal cost-sharing). You cannot be charged for the days your coverage is being appealed, even if the appeal is ultimately decided against you.

If you wait until after discharge to appeal, you lose this protection. Time is critical.

The Hospital-Issued Notice of Non-Coverage (HINN)

When a hospital determines that Medicare will no longer cover your stay, it must provide you with a Hospital-Issued Notice of Non-Coverage (HINN). This written notice must:

• Explain why Medicare coverage is ending
• State the specific date coverage will end
• Tell you how to appeal if you disagree
• Include the BFCC-QIO contact information

You should receive the HINN at least 2 days before your coverage is scheduled to end. If you do not receive a HINN, ask the hospital's discharge planner or social worker for one. Without a proper HINN, the hospital may not be able to charge you for the days in question.

For skilled nursing facilities, the equivalent notice is the Notice of Medicare Non-Coverage (NOMNC), also provided at least 2 days before coverage ends.

How to Contact the BFCC-QIO Immediately

The Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) is your first call for a discharge appeal. The BFCC-QIO is an independent organization contracted by CMS to review Medicare coverage decisions. There are two BFCC-QIOs:

• Livanta: Serves many states (contact information on your HINN/NOMNC)
• KEPRO: Serves other states (contact information on your HINN/NOMNC)

The process:

1. Receive your HINN or NOMNC
2. Call the BFCC-QIO the same day — do not wait
3. Request a review of the discharge decision
4. Your Medicare coverage continues while the QIO reviews your case
5. The QIO will contact your provider and review your medical records
6. You will receive a written decision typically within 1 business day for hospital cases, 2 business days for SNF cases

What the QIO Reviews

The BFCC-QIO reviews whether the discharge is appropriate given your current medical condition. They consider:

• Whether you still require the level of care being provided
• Whether continuing care is medically necessary
• Whether alternatives (like home health or lower-level care) are appropriate for your condition at this time

The QIO does not simply rubber-stamp the hospital's decision. If the QIO agrees with you, your coverage continues. If the QIO agrees with the hospital, you have additional appeal options.

If the QIO Upholds the Discharge

If the QIO finds the discharge appropriate, you can still file a formal Medicare appeal. Your coverage ends at the conclusion of the QIO review, but you can pursue a retroactive appeal for the days in question through the standard 5-level process:

1. Redetermination by the MAC — file within 120 days
2. Reconsideration by the QIC — file within 60 days
3. ALJ Hearing at OMHA — file within 60 days
4. Medicare Appeals Council — file within 60 days
5. Federal District Court — for qualifying cases

What to Say When Calling the QIO

When you call the BFCC-QIO, tell them:

• Your full name and Medicare number
• The hospital or SNF name and your room number
• The date your coverage is scheduled to end (from the HINN/NOMNC)
• That you are requesting a review of the discharge decision
• That you believe you still medically need the level of care being provided

Get the name of the QIO representative you speak with and the date and time of the call.

Involving Your Doctor

Ask your treating physician to communicate to the QIO that continued care is medically necessary. A physician who actively supports your continued stay — and can articulate the clinical reasons — significantly strengthens your appeal. Your physician has the right to speak directly with the QIO reviewer.

If You Are Being Pressured to Leave

Hospitals and SNFs sometimes pressure patients to leave before the formal notice period expires, or before an appeal is completed. You have the right to stay in your current setting while your appeal is pending, with Medicare coverage continuing. If you feel pressured, contact your SHIP counselor or a patient advocate immediately.

Free Help: SHIP Counselors

SHIP counselors (shiphelp.org) are trained in Medicare discharge rights and can walk you through the QIO appeal process in real time. Contact them the same day you receive a discharge notice.

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Related Reading:

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Internal vs External Insurance Appeal