Medicare Patients' Rights Overview
Medicare Quality Improvement Organizations (QIOs) were created by
Congress in 1984 to protect the rights of persons with Medicare and to
protect the Medicare Trust Fund by assuring that Medicare was paying for
medically necessary care in the appropriate health-care setting.
These services are free to persons with Medicare. Since 1984, Medicare QIOs
have been protecting three basic Medicare rights.
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You have the right to receive good quality health care that meets established standards and guidelines. You have this right if you have standard fee-for-service Medicare, now known as Original Medicare, or if you are enrolled in a Medicare Managed Care Plan (MMCP). For more information, read Quality-of-Care Complaints.
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You have the right to be admitted to the hospital when it is medically necessary. This right extends only to those persons with Original Medicare. It does not apply if a person is enrolled in a MMCP. For more information, read Hospital Admission.
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You have the right to stay in the hospital until it is medically safe for you to leave. This right protects you from being discharged from the hospital too soon. You have this right if you have Original Medicare or if you are enrolled in a MMCP. For more information, read Early Discharge.
Know Your Responsibilities
As a person with Medicare, your responsibilities are to
- talk to your doctor about your concerns regarding your medical care,
- become an educated health-care consumer, and
- take an active role in making changes that help you lead a healthier life,
Early Discharge
Medicare QIOs were created to protect the rights of persons with Medicare in
every state and U.S. territory in 1984 when Medicare changed its hospital
payment system. To help control rising health-care costs, Medicare began
paying acute care hospitals a flat fee, based on a patient's diagnosis
related group. This means that Medicare pays the hospital based on your
diagnosis-the type of illness or injury you have-and not by the number of days you
stay in the hospital.
People frequently ask, "How long should I stay in the hospital for this
particular illness?" The answer is always the same; you should stay in the
hospital as long as it is medically necessary for you to be there.
Therefore, how long you stay in the hospital should be based on your medical
needs, not on your diagnosis. To protect you from being discharged too soon,
Medicare has
established a free appeal process.
An Important Message from Medicare
Each time a person with Medicare is admitted to the hospital, he or she
should receive a document titled "An Important Message from Medicare." You should
receive this document if you have Original Medicare or a MMCP. This notice
explains how to request an appeal of your planned discharge from the
hospital. You should receive a copy of this notice no more than 2 days prior
to discharge. This notice explains how to request an appeal of your planned
discharge from the hospital.
Talk to your doctor about your stay in the hospital
You and your doctor know more about your condition and your health needs than anyone else. Decisions about your medical treatment should be made between you and your doctor. If you have any questions about your medical treatment, your need for continued hospital care, your discharge, or your need for possible post-hospital care, don't hesitate to ask your doctor. The hospital's patient representative or social worker will also help you with your questions and concerns about hospital services.
If You Think You Are Being Asked To Leave the Hospital Too Soon
If you are ever told you must leave the hospital before you feel well enough, you have the right to appeal that decision by asking the Medicare Quality Improvement Organization (QIO) in your state to perform a free review of your case. If you are a patient in an Indiana or Kentucky hospital, Health Care Excel is the organization to call. You can think of this review as your right to have a second doctor's opinion about being medically ready to leave the hospital. You have this right if you have Original Medicare.
How Do I Appeal?
In order for the Medicare QIO to perform a review, you must:
- Call the Medicare QIO prior to midnight on
the planned day of discharge using the phone number on the notice. A
friend or family member may make the call for you.
- Inform the hospital that you called Health Care Excel, the Indiana and Kentucky Medicare QIO.
The Review
When you call the Medicare QIO, you will be asked for your name, telephone number, Medicare number, the name of the hospital you are in, the date of the planned discharge, and some questions about your situation. The QIO will then call the hospital for a copy of your medical record. The hospital must send the record to the Medicare QIO within 24 hours. Once your record is received, one of the QIO physicians will review your case to decide whether or not you need to stay in the hospital. If the doctor decides that you need more hospital care, you can stay in the hospital and Medicare will pay.
Medical Necessity
If the QIO finds that you do not need continued acute hospital care, Medicare will no longer pay for your hospital stay after the Medicare QIO has made its decision. (Please remember that medical necessity is based on whether the care you need can be provided only in a hospital, not on your desire to stay in the hospital.)
If you stay in the hospital after the Medicare QIO says that Medicare will no longer pay, you will have to pay for the rest of your hospital stay. Note: You will not be charged for your hospital stay during the Medicare QIO's review, even if we agree with the hospital that you no longer need acute hospital care.
Quality-of-Care Complaints
Medicare wants to make sure that you are getting care that meets established standards and guidelines. If you do not think you are currently getting (or did not get) good care from an Indiana or Kentucky hospital or hospital emergency department, skilled nursing or rehabilitation facility, ambulatory surgery center, doctor's office, or home health agency, call Health Care Excel. We will conduct a free review of the care. This right applies to everyone on Medicare, including those enrolled in a MMCP.
The following are not considered to be concerns subject to Health Care Excel's review:
- Cold food
- Not enough food
- Incorrect room temperature
- Rude staff
- Poor housekeeping
- Untimely staff response not resulting in harm
If you are currently in a health-care facility and you have a quality-of-care complaint, the Medicare QIO's review will begin as soon as your phone call is received.
If you have already been released from the facility, you (or someone on your behalf) can call the Medicare QIO's Helpline at 1-800-288-1499 to discuss your complaint and request a complaint form. The form asks for the patient's name and Medicare number, the date of admission, the name of the facility that provided the care, and a description of your quality concerns. Or, you may send the Medicare QIO a letter that includes the information mentioned above. A Medicare QIO staff member will be happy to assist you in writing your complaint should you need assistance.
A formal review will begin as soon as your written complaint is received. The Medicare QIO will then request a copy of your medical record from the health-care facility. A doctor will perform the review of your medical record. This review can take three to six months to complete. You will be updated on the progress of the review and notified once the review is completed.
Your Confidentiality
The Medicare QIO knows that patients often do not want their doctor to know that they have filed a complaint. Be assured that a review can be completed without your doctor ever knowing that you requested the review. In a confidential quality-of-care review, the Medicare QIO's findings are discussed with the doctor or facility; the patient (or family member) requesting the review will not be identified and will not be told of the results. If you want to know the results of the review, the physician or facility will have to be told that you made the request.
The Medicare QIO's Findings
If the Medicare QIO finds a concern with the quality of care that you received, the QIO representative will talk to the facility and/or doctor to recommend ways to handle the same situation in the future. This helps to improve future care provided by the doctor or facility.
In rare cases, the Medicare QIO may recommend that a facility or doctor be removed from the Medicare program. This is done only as an absolute last resort when every attempt to work with the doctor or the health care facility to correct the problem has failed. The Medicare QIO's aim is not to punish health-care providers, but to protect patients by helping to improve the quality of health-care provided to all patients.
Post-Hospital Care
When your doctor determines that you no longer need all the specialized services provided in a hospital, but you still require medical care, he or she may discharge you to a skilled nursing facility or home care. The discharge planner at the hospital will help arrange for the services you may need after your discharge. Medicare and supplemental insurance policies have limited coverage for skilled nursing facility care and home health care. Therefore, you should find out which services will or will not be covered and how payment will be made. Consult with your doctor, hospital discharge planner, hospital patient representative, and your family in making preparations for care after you leave the hospital. Don't hesitate to ask questions.
Hospital Admission
If your doctor believes that you need to be admitted to an Indiana or Kentucky hospital, but the hospital does not believe that you require acute medical care, you may appeal that decision to the Medicare QIO. While this happens very rarely, it is nice to know that you have free appeal rights. Please note that this is a right for persons with Original Medicare only; it does not apply for those enrolled in Medicare+Choice plans such as HMOs. When this happens, the hospital will send you a letter called an "admission denial". It basically says that the hospital does not think Medicare will pay for your stay because it is not medically necessary.
Your Responsibilities
The Medicare QIO's telephone number will be on the admission denial letter from the hospital. It is your responsibility to call and ask for a free review. When reviewing your case, the Medicare QIO representative will speak with you, your doctor, and the hospital. We will obtain a copy of your medical record to determine if you are being wrongfully denied admission to a hospital. We will inform you of our decision when the review is complete. If we determine your admission is medically necessary, Medicare will pay for your stay. If the Medicare QIO agrees with the hospital, Medicare will not pay for your hospital stay.
Indiana or Kentucky Medicare Beneficiary Helpline:
1 (800) 288-1499
