Medicare Is Discharging You Too Soon ... How to Appeal

What This Means

Medicare or your plan has determined that your medical condition no longer requires the level of care you are receiving — in a hospital or skilled nursing facility (SNF) — and has set a date for your coverage to end. Getting this notice feels abrupt, and the financial stakes are real. What many people don’t know is that you have a legal right to appeal that decision before you leave, and if you request the appeal in time, you can typically stay put while it is reviewed.

Why This Happens

• Medicare’s clinical criteria are not always aligned with how you feel. Coverage decisions are based on whether your condition meets specific medical criteria, not solely on whether you or your doctor believe more time is needed.
• Utilization reviewers flag cases for discharge. Hospitals and SNFs have internal teams that monitor patient status against Medicare’s coverage guidelines. When those guidelines are no longer met on paper, a discharge notice is generated.
• Your progress has been reclassified. In an SNF, Medicare Part A covers skilled care — meaning daily nursing or therapy with a measurable goal. If your care is deemed maintenance rather than skilled improvement, coverage may be cut off.
• The documentation didn’t fully capture your condition. Medical records submitted to reviewers may not have reflected the full picture of your daily needs, which can lead to an earlier-than-warranted discharge decision.
• Medicare Advantage plans apply their own criteria. If you have a Medicare Advantage plan (a private plan that provides Medicare benefits), your plan’s reviewer — not Original Medicare — made this call, and the criteria can differ.

Should You Appeal?

What To Do Next

1. Read the discharge notice immediately. Medicare requires that hospitals and SNFs give you a written notice before ending coverage. For hospitals, this is called the Important Message from Medicare About Your Rights. For SNFs, it is the Notice of Medicare Non-Coverage. Both notices must include a deadline and contact information for your appeal.

2. Request a fast-track appeal by noon the day after you receive the notice. For Original Medicare, you contact your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) — the federally contracted reviewer listed on your notice — not Medicare directly. For Medicare Advantage, call the number on your notice for your plan’s designated reviewer. Missing this window means you may owe for the days of care you could have kept covered.

3. Tell your doctor right away. Your physician’s support is the most important piece of your appeal. Ask them to confirm in writing — to you and to the reviewer — that continued care is medically necessary.

4. Stay in place while the appeal is under review. If you filed before the deadline, Medicare cannot bill you for the days your appeal covers until a decision is made. You are protected during that window.

5. If the first decision goes against you, ask about the next level of appeal. A denial at the fast-track level is not the end. You can escalate through Medicare’s standard appeals process — reconsideration, then an administrative law judge hearing, and beyond. Each level has its own deadline, so act promptly.

6. Call 1-800-MEDICARE (1-800-633-4227) or your State Health Insurance Assistance Program (SHIP) if you need help. SHIP counselors are free, unbiased, and experienced with discharge appeals. They can walk you through the process specific to your state.

Sources

• Medicare.gov — How to file a complaint or appeal
• Medicare.gov — Original Medicare appeal levels
• Medicare.gov — Skilled nursing facility (SNF) care
• Medicare.gov — Inpatient hospital care

Frequently Asked Questions