Transcript How to Have a conversation with Hospital Staff about your

How to Have a conversation with
Hospital Staff about your Status and
Discharge
New York StateWide Senior Action
Council Teach In
November 21, 2013
Nora Baratto, ACM LCSW-R
Director, Case Management
Preparation is KEY!!
Know your insurance, read the definitions
know coverage, exclusions, deductibles,
copays and provider network
 If you do not understand your insurance Call
Senior Action council , local HIICAP program
counselor, Health care advocate to help you
understand the terminology.
 Have a power of attorney and health care
proxy in place.
Keep everything in a file and update it inform
family of file in event of emergency.
Be an active participant in your Care
 You are your own best advocate. If you are unable to
advocate for yourself designate someone you trust
…..Health care agent.
 Ask to speak with your D/C planner immediately and
inform them of what your expectations are relative to
D/C.
 Hospital staff including physicians are required to follow
state and federal regulations cannot change Medicare
rules i.e. we can’t make a patient an inpatient for three
days just so they qualify for skilled nursing care. Patient
status is based on Medicare and hospital guidelines.
Know your Right’s as a Patient – NYS DOH
“Your Rights” Booklet can be found at: http://www.health.ny.gov/publications/1449.pdf
Right to know your patient status.
- Observation status is assigned when the physician
needs to due further testing and evaluation to make
decision if admission is required. Typically
observation status is usually only for up to 48 hours
- Ambulatory Care- outpatient surgery/procedure
- Inpatient Status -Medical necessity is what
determines status. You need to be acutely ill and
require the 24/7 expertise of physicians and RN
continuous monitoring of a serious illness.
- Custodial Care (24 hour supervision that does not
require RN monitoring) can be provided in
another setting.
- Many consumers mistakenly think if they can’t
care for themselves their insurance will cover.
Patient Right’s D/C Planning
Right to be actively involved in your d/c plan.
if unable designated legal representative can
act
 Right to choose post acute providers of care.
 Right to refuse D/C plan
 Right to receive D/C plan in writing
Be informed 48-24 hours in advance of D/C in
writing
Can appeal your D/C through IPRO
Appeal Rights
 If you are in observation status and the physician
determines that you do not need to be admitted
but you cannot return home. You would be issued
an admission denial. You should appeal to your
insurance company.
 While waiting for the decision you will not be
charged until a decision is made.
 If an inpatient and you no longer need acute
level of care you will be informed and can appeal.
Once again you will not incur any charges until a
decision is made.
If You Think You Are Being Asked to Leave
the Hospital Too Soon. . .
You have the right to appeal decisions made by your doctor, hospital staff or your managed care plan:
about when you are to leave the hospital;
if you feel you are being asked to leave the hospital too soon;
if you believe you have not been given adequate or appropriate plans for your medical care and other services you may need after
you leave the hospital;
or
if needed services are not in place.
The law requires that you receive advance notice in writing telling you:
the date the physician and/or hospital plans to discharge you;
how to appeal if you wish to remain in the hospital; and
a special number to call with any problems related to leaving the hospital.
For Assistance/Help
There is an Independent Professional Review Agent (IPRA) for your area and your insurance coverage. Should you need
assistance/help from the IPRA, the hospital will provide you with a phone number/ person to contact. See the Glossary for more
information.
For Medicare Patients Only
If you feel that you are being asked to leave the hospital too soon and have not received advance notice telling you when to leave the
hospital, ask for your discharge notice (called "The Important Message from Medicare about Your Rights"). If you are in a Healthcare
Maintenance Organization (HMO), you should also request "The Important Message from Medicare about Your Rights". You must
have this written discharge notice in order to appeal the physician's and hospital's decision about when you are to leave. See an
"Important Message from Medicare about Your Rights" for a complete explanation.
For Managed Care Patients
If you are a patient enrolled in an HMO or managed care plan, first request/submit an expedited appeal to the HMO or plan's
utilization review committee if you feel your benefits are unfairly limited or denied, or you are being asked to leave the hospital too
soon, or that medically necessary services are inappropriately excluded from your coverage. If you are not satisfied with the outcome
of that appeal request, you may contact the New York State Department of Health by calling: 1-800-206-8125.
The Managed Care Law of 1996 amending Public Health Law 4408, Disclosure of Information
Appealing a Discharge or Quality
Problem
• IPRO —This is the quality improvement
organization contracted by the federal and state
government to review the hospital's care
provided to Medicare and Medicaid patients in
New York State.
• Appealing a discharge : Contact if you believe
you are being discharged too soon from the
hospital. Call toll-free at 1-888-880-9976.
• For complaints about the quality of hospital care
you can call the Medicare Hotline toll free at 1800-331-7767.
Know your D/C options
Skilled Home Care - short term need MD
order
Case Management Services
 Short term rehabilitation in skilled nursing
facility
Respite services
Community program local office for aging and
senior services
Mobile meals, Lifeline
Tips for success
 Please focus on “how you can prevent coming to
the hospital”
 have an in home assessment and develop a plan .
If you see a decline in your health see your
physician and ask for homecare to assess you
 If you end up in the hospital request a meeting
with your D/C planner to develop a plan of care.
 Request to see a patient representative in the
hospital or a social worker if you feel your needs
are not being met.
Questions