As a Medicare beneficiary, you have guaranteed rights. These rights apply to people in the traditional Medicare program as well as those in Medicare Advantage Plans. It is important to know your rights, and how to use them.
Sometimes, payment for hospital and other health care services is discontinued because it has been decided that the care is no longer medically necessary. Medicare has asked IPRO, the Medicare Quality Improvement Organization (QIO) in New York State, to review cases like these, and decide whether or not it is appropriate for Medicare to continue to pay for these services.
What does this mean?Sometimes, you may not be happy with the kind of care you received in the hospital or from other health care providers. In these cases, you may file a complaint through IPRO's Beneficiary Complaint Response Program. Or you may use an alternative dispute resolution method, such as mediation, to resolve your concerns. In this issue of Healthy Seniors, we'll look at how to use your Medicare rights.
Return to topWhen you are admitted to the hospital you should receive a notice called "An Important Message from Medicare." This notice explains your right to appeal your discharge and describes what to do if you feel you are being discharged too soon.
All Medicare beneficiaries have the right to:
If you disagree with your discharge plan, request a notice in writing. People enrolled in traditional Medicare should get a Hospital Issued Notice of Non-Coverage (HINN). People in Medicare Advantage plans should receive a Notice of Discharge and Medicare Appeal Rights (NODMAR).
Timing is important. When you receive one of these notices, call before noon of the next working day following your receipt of the notice to gain quick access to your appeal rights.The number to call to appeal your discharge from the hospital is 1-800-446-2447.
Return to topWhether you are enrolled in traditional Medicare or in a Medicare Advantage plan, you have the right to appeal if certain services you receive outside the hospital are being discontinued.
Traditional Medicare If you are enrolled in the traditional Medicare program, you have the right to request an independent review, called an Expedited Determination, of a decision to discontinue services you receive from a home health agency, skilled nursing facility, a hospice, or a CORF (comprehensive outpatient rehabilitation facility).If services like these are being discontinued, you or your representative should receive a form called a Notice of Medicare Provider Non-Coverage from the health care provider at least two days before the services are scheduled to end. This notice tells you when payment for the services will end, and how to appeal.
IPRO's toll-free number for these appeals is 1-800-833-0356 (TTY 866-446-3507). This number is available seven days a week between 8:30 am and 4:30 pm, including Saturday, Sunday and holidays.
Note: If you receive services in a non-residential setting, like a home health agency or an outpatient rehabilitation facility, a physician must certify that discontinuation of services may pose a significant risk to you. This certification is necessary in order to continue your appeal process. Medicare Advantage If you are enrolled in a Medicare Advantage Plan, you have a right to a Fast Track Appeal if payment for services you receive in a skilled nursing facility, home health agency or comprehensive outpatient rehabilitation facility is being discontinued.Your plan is required to tell you in writing when your services are expected to end. When you receive that notice, called a Notice of Medicare Non-Coverage, call IPRO to ask for a "Fast Track" appeal. The number is 1-888-696-9561 (TTY 866-446-3507).
This line is also open seven days a week from 8:30 am to 4:30 pm.
What happens when you request an Expedited Determination or a Fast Track Appeal?First, IPRO will notify your health care services provider of your decision to appeal. IPRO will ask the provider for a detailed explanation of why your coverage is ending, and any additional information we need to review your case. This information must be received by IPRO no later than the close of business the day after you appeal. The provider should also send you a copy of everything they send to IPRO.
Note: A physician must certify that discontinuation of services may pose a significant risk to you. IPRO will ask you for this "physician certification."An independent IPRO physician will review your case and make a determination. You will be notified of the decision by telephone and in writing, most often within 72 hours from the time you called to request an expedited review of your case. We will also notify the provider of the services and your physician of our determination.
If the IPRO physician reviewer agrees with you that the services you are receiving are appropriate and eligible for payment, the provider will continue those services.
If the physician reviewer at IPRO agrees with your provider, Medicare will not pay for the health care services after the date on the original notice. However, you will be advised of the next steps available to you, should you wish a reconsideration of this decision.
Return to topIf you have concerns about the quality of care you received, you have a right to complain. To file a complaint you may call 1-800-MEDICARE (1-800-633-4227) or call IPRO directly at 1-800-331-7767.
To begin filing a complaint to IPRO's Beneficiary Complaint Response Program, be prepared with the following information:
Your complaint must be submitted in writing. If you wish, IPRO can help you with your written complaint.
How does IPRO follow up on your complaint?Quality of care complaints that have been submitted in writing enter the Beneficiary Complaint Response Program. Physicians and nurses at IPRO review medical record information related to the services that are the subject of the complaint. With your consent, both you and the provider(s) of the services are notified of the outcome of this review.
Mediation: Another Way to Be Heard Mediation is another option available to you if you have a complaint about the care you received. An IPRO physician reviewer can refer a case to mediation. Mediation will involve a conversation between you and your doctor or hospital. This discussion is facilitated by an impartial third person, the mediator.Mediation can help resolve your concerns about the way you were treated. It provides an opportunity for you and your doctor and/or hospital to hear each other's version of events, respond to each other, and reach a mutually agreeable resolution.
Return to topIf you are in a Medicare Advantage plan and receive a Notice of Medicare Non-Coverage, you may ask for a "Fast Track" appeal.
Call IPRO at 1-888-696-9561 (TTY 866-446-3507). Both telephone lines are open seven days a week from 8:30 am to 4:30 pm, even on Saturday, Sunday and holidays.
Quality of Care: If you have concerns about the quality of care you received, call IPRO at 1-800-331-7767. Return to top