The Centers for Medicare and Medicaid Services recently adopted a new rule in response to a federal district court decision requiring the Department of Health and Human Services to expand appeal rights under the Medicare program for beneficiaries who experience changes in patient status while receiving care.
What Are Medicare Patient Status Changes?
A Medicare patient status change may occur when a Medicare beneficiary initially goes into a hospital or other healthcare facility as an inpatient, but the facility reclassifies the patient as an outpatient receiving observation services. This reclassification can negatively affect a patient’s ability to have their treatment covered by Medicare. Reclassification may result in Medicare denying coverage for skilled nursing benefits, potentially leaving patients responsible for care expenses and upsetting the careful Medicaid planning that families have undertaken.
Key Appeal Rights for Medicare Beneficiaries
Medicare beneficiaries may appeal coverage decisions following a change in patient status from inpatient to outpatient when those beneficiaries meet other criteria. These appeal rights include:
- Expedited appeal – Eligible beneficiaries may request an expedited appeal before leaving a healthcare facility to challenge their reclassification, with these appeals heard by a Beneficiary & Family Centered Care Quality Improvement Organization.
- Standard appeal – Beneficiaries who do not request expedited appeals can still use the standard Medicare appeals process.
- Retrospective appeal – Beneficiaries may also request a retrospective appeal to challenge a status change from as early as January 1, 2009. However, beneficiaries must file such appeals within 365 days of the rule’s implementation date, which is still pending.
How Amoruso & Amoruso LLP Can Help
If your healthcare facility changes your or your loved one’s admission status from inpatient to outpatient and Medicare has denied coverage, or you have an unresolved claim, contact Amoruso & Amoruso LLP today. We may be able to provide you with a reliable referral to pursue your options for an appeal and can help you plan for your or your loved one’s future long-term care needs.
