Securing Quality Care – Nursing Home Appeals

Nursing Homes

Elderly adults end up in nursing homes for a variety of reasons, including rehabilitation after a hospital stay, voluntary admittance in order to have assistance with their daily care, disability, as well as problematic behaviors associated with mental conditions such as dementia. In order to be admitted and afford to one of these nursing homes, many elderly adults rely on government programs such as Medicaid and Medicare. As a result of their reliance on government funded programs, some nursing homes will end services for an individual if their coverage is running out or they feel that the patient is ready for release, however, the patient may not agree with that same reasoning.


Why Am I Being Discharged?

According to federal regulations there are only a handful of reasons by which a patient may be discharged, regardless of coverage. Discharge from a facility can occur if the individual’s health improves, the facility can no longer meet the health care needs of the individual, the individual has endangered the health and safety of others, the health care facility no longer is operating, or if the individual has failed to pay for their services.


Medicare Coverage

In the case of government funded healthcare assistance, if the patient feels their services in the nursing home are ending prior to their complete or adequate rehabilitation, they can get a fast appeal if they are receiving care at a Medicare covered skilled nursing facility, a Medicare covered home health agency, a Medicare covered comprehensive outpatient rehabilitation facility, or a Medicare covered hospice facility. The patient should receive a Notice of Medicare Non-Coverage at a minimum of two days prior to discharge. This notice must detail the patient’s right to an expedited review of their discharge.


Upon receiving the notice, the patient can file a fast appeal with the Beneficiary and Family Centered Care Quality Improvement Organization. The beneficiary must request a health care plan that provides reports describing what has transpired to formal grievance and appeal data, using a standardized formula. If an appeal is filed, the plan must give a notice as to why services should end for this beneficiary. Since this may be overwhelming for many beneficiaries, the beneficiary can appoint a person to file a grievance on their behalf as well, or to request an organization determination or request an appeal.

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