What Can I Do if I Think a Family Member Is Being Discharged from a Skilled Nursing Facility Too Soon?

Emily WhicheloeDear Marci0 Comments

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Dear Marci,
My mother has Original Medicare and is currently receiving care from a skilled nursing facility. Her provider gave her a notice saying that she will be discharged soon, but she does not feel she is ready to go home. Is there any way she can stay in the skilled nursing facility and get Medicare to cover the stay?Judy (Rockford, IL)

Dear Judy,

Yes, your mother can appeal to Medicare to request that her skilled nursing facility stay and coverage continue. The notice her provider gave her was a Notice of Medicare Non-Coverage, which contains information about how your mother should begin her appeal. This appeal is expedited, meaning that you will quickly know whether the appeal is accepted or denied.

Your mother can start her appeal by contacting the Beneficiary and Family Centered Care – Quality Improvement Organization (BFCC-QIO or QIO for short) by, at the latest, noon of the day before her care is set to end. It is best to contact the QIO as soon as possible.

Next, the QIO will alert your mother’s provider of the appeal and collect the information it needs to review the case. Once the provider learns about the appeal, they should give your mother a Detailed Explanation of Non-Coverage that explains why the care is ending. This notice will also list any Medicare coverage rules related to her case. Your mother should receive this notice within the same day that her provider learns about the appeal from the QIO.

In addition to information supplied by the provider for your mother’s appeal, you and she can submit your own evidence to support her need for continued SNF care—but this is not required.

After submitting evidence, your mother may speak with the QIO on the phone again or submit a written statement about why her care should continue. The QIO will decide if Medicare will continue to cover care based on the information it receives from the SNF and your mother. The QIO must give your mother a decision no later than two days after her Notice of Medicare Non-Coverage says her care is set to end. This decision can be made by telephone but must also be sent in writing.

If the QIO decides that your mother’s care should continue, she should continue to receive care as long as her provider continues to certify it.

If the QIO decides that your mother’s care should not continue, your mother can choose to move on to the next level of appeal.

Throughout the appeal process, it is important to keep copies of all documents, write down the names of people you speak to on the phone, and send appeal paperwork through certified mail. Good luck!

– Marci

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