If you were admitted to the hospital as an inpatient and the hospital later changed your status to "outpatient getting observation services," you can ask for a fast appeal. Medicare.gov says you should get a "Medicare Change of Status Notice" (CMS-10868) before you leave, and it tells you how to contact your state's reviewer, called a BFCC-QIO. It's best to appeal while you're still in the hospital, though you can still appeal after you leave.
Why does a status change matter?
Medicare.gov lists what changes when you go from inpatient to observation:
- Your stay is billed to Part B, where it would have been Part A. Depending on the Part B coinsurance you owe, your hospital bill may be lower or higher than the Part A inpatient deductible.
- If you don't have Part B, the hospital will charge you the full cost of your outpatient stay.
- Medicare won't pay for a skilled nursing facility after you leave the hospital.
That last point can matter most. If a parent needs rehab in a nursing home after the hospital, the status decides whether Medicare helps pay. See skilled nursing facility bills and Medicare and observation status vs. inpatient.
What notice should I get?
Medicare.gov says that if your status changes from inpatient to outpatient getting observation services during your stay, you should get the Medicare Change of Status Notice (CMS-10868) before you leave the hospital. It explains the billing change, the effect on nursing home coverage, and your right to a fast appeal, with contact information for the BFCC-QIO.
If you don't get it, ask for it.
What to say to the nurse or case manager:
"I understand [patient name]'s status was changed from inpatient to observation. Can we please have the Medicare Change of Status Notice? We may want to appeal."
This notice is different from the Medicare Outpatient Observation Notice (MOON), which tells you you're under observation. See the Medicare Outpatient Observation Notice.
How do I ask for the fast appeal?
Follow the instructions on the Change of Status Notice. The BFCC-QIO for your state is run by Commence or Acentra, depending on where you live, and the notice gives the contact information. If you can't find the notice, Medicare.gov says you can contact your local BFCC-QIO directly.
What to say to the BFCC-QIO:
"I'm calling to appeal a change in hospital status for [patient name] at [hospital name]. They were admitted as an inpatient on [date], and the hospital changed their status to outpatient getting observation services on [date]. We'd like a fast appeal. What do you need from us?"
Write down the date, time, name of the person you spoke with, and any reference number.
What happens after I file?
Medicare.gov says the BFCC-QIO will:
- Let the hospital know you filed.
- Ask the hospital for medical records.
- Give the hospital a chance to explain why the change was appropriate.
- Review the records and the hospital's explanation.
- Decide and tell you about 2 days after you file.
You can ask for copies of the materials sent to the BFCC-QIO.
What happens if I win or lose?
Medicare.gov describes both outcomes:
If the reviewer decides your status shouldn't have changed:
- You pay the Part A inpatient hospital deductible.
- You may qualify for a Medicare-covered skilled nursing facility stay within 30 days of discharge, if other requirements are met.
If the reviewer decides your status should have changed:
- You pay Part B costs, if you have Part B.
- Without Part B, you may owe the full cost of the outpatient stay.
- You won't qualify for Medicare-covered skilled nursing facility care after this stay.