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Your Rights as a Medicare Hospital Patient
You have a right to receive all the hospital services necessary for the proper diagnosis and treatment of your illness or injury. Your discharge date should be determined solely by your medical needs, not by a “diagnostically related group” classification (DRG) or by Medicare payments. You have the right to be fully informed about decisions affecting your Medicare coverage or payment for your hospital stay and for any post-hospital services. You have a right to appeal any written notices you receive from the hospital or Medicare stating that Medicare will no longer pay for your care.
Talk to Your Health Care Team
You and your health care team know more about your condition and your health care needs than anyone else. If you have questions about your medical treatment, your need for continued hospital care, your discharge or your need for post-hospital care, consult your health care team.
These decisions should be made between you and your health care team.
If you have questions or concerns about hospital services, you should talk to the hospital’s patient representative or discharge planner. Don’t hesitate to ask questions about your care, your stay in the hospital, and your planned discharge.
Peer Review Organizations
Peer Review Organizations (PROs) are groups of doctors who are paid by the federal government to review medical necessity, appropriateness, and the quality of hospital treatment furnished to Medicare patients. Peer Review Organizations will respond to your request for review and appeal of written notices stating that Medicare will no longer pay for your hospital stay.
If you think you are being asked to leave the hospital too soon, ask a hospital representative for a written notice of explanation immediately, if you have not already received one. The hospital’s written notice is necessary if you decide to appeal to the PRO. The written notice must describe how you appeal. If you decide to appeal, do so immediately by either calling or writing the PRO.
If you lose the appeal, you may be billed for all costs of stay beginning with the third day after you receive the written notice. The PRO will inform you in writing of its decision on the review. You cannot be made to pay for your hospital care until the PRO makes its decision if you request the review by noon of the first working day after you receive the notice.
Remember: Without a written notice from the hospital, you have no right to appeal.
Post-Hospital Care
When your doctor determines that you no longer need all the specialized services provided in a hospital, but you still require medical care, he or she may discharge you to a skilled nursing facility or home care. The discharge planner at the hospital will help arrange for the services you may need after your discharge. Medicare and supplemental insurance policies have limited coverage for skilled nursing facility care and home health care. Therefore, you should find out which services will or will not be covered and how payment will be made. Consult with your doctor, hospital discharge planner, patient representative, and your family in making preparations for care after you leave the hospital. Don’t hesitate to ask questions.
Disclosure of PRO Confidential Information
Any medical data collected by MassPRO pertaining to a specific beneficiary will not be disclosed to anyone except in accordance with Federal Regulations 42 CFR 476.116 (b). For further information concerning confidentiality of your medical data, contact the Confidentiality Officer at MassPRO.
The Peer Review Organization for this area is:
Massachusetts Peer Review Organization
Manager, Reconsideration,
MassPRO, 300 Bear Hill Road
Waltham, MA 02154
Telephone: 781-890-0011, ext. 2830
Rights of Medicare Beneficiaries Under Massachusetts Law
Under Section 51D of Chapter 111 of the Massachusetts General Laws, you have certain rights as a Medicare beneficiary. The following is a summary of these rights:
Acute Care hospitals cannot discriminate against Medicare patients with regard to admission, availability of services, treatment, transfer or discharge. Hospitals must treat Medicare patients in the same way that all patients with comparable medical needs are treated. In addition, acute care hospitals are required to create individualized discharge plans consistent with medical discharge orders
and identified patient needs.
An advocacy office for handling complaints of alleged violations of the provisions of this section has been established by the Massachusetts Department of Public Health. This office is located at 10 West Street, Boston, 617-753-8000 or 800-462-5540. The Attorney General has been authorized to bring a civil action to enforce the provisions of this section.
The rights of Medicare patients under this section are in addition to any other rights provided by law to Medicare patients.
If you have questions concerning your medical rights or if you would like a copy of the full text of section 51D, please contact the Medical Center’s Admitting/Registration areas.
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