Hospital discharge happens fast. The hospital has financial incentives to move it along. The case manager works for the hospital, not for you. Understanding your rights and asking the right questions before the day of discharge changes what options are available.
Dollar figures reflect 2025 Medicare rates. CMS adjusts these annually. Verify current rates at medicare.gov before making decisions.
Topic one
How discharge actually works
Discharge planning begins on day one of a hospital stay, not the day before you leave. Understanding who is driving the process and what they are working toward helps you engage at the right time with the right people.
Hospitals are reimbursed at a flat rate per diagnosis under Medicare. Discharging patients sooner retains more of that reimbursement.
This is not a criticism of hospitals - it is how the CMS Prospective Payment System works. A hospital that keeps a patient three extra days when two would have been sufficient bears those costs without additional reimbursement. Understanding this incentive structure helps you interpret discharge pressure correctly. It also explains why the case manager is a hospital employee focused on a safe and timely discharge rather than on your optimal outcome specifically.
1
The case manager is assigned at or near admission
Most patients meet their case manager close to discharge. You do not have to wait. Request a meeting on day one or two. The case manager controls what post-acute options you are presented with, what equipment gets ordered, and how much time you have to make decisions.
2
The discharge destination is determined partly by clinical criteria, partly by what is available
The clinical picture - your functional level, medical needs, and support at home - should drive where you go. But bed availability, insurance approval, and the case manager's familiarity with local facilities also shape the options presented. Ask for the full list of certified facilities in your area, not just the suggested one.
3
Insurance often receives discharge notification before the patient does
Under Medicare Advantage, the plan's utilization management team may review the stay daily and issue a discharge recommendation before the clinical team formally plans discharge. Ask the case manager whether the plan has issued any utilization recommendations and what criteria they are using.
4
Discharge day often moves faster than expected
Discharge orders can be written in the morning for a same-day discharge. Equipment ordered on discharge day often does not arrive until the next day or later. Ask the case manager how much notice you will have before the discharge date is set, and confirm that all ordered services and equipment will be in place before you leave.
Topic two
Your rights at discharge
Medicare establishes specific rights at the point of discharge. Most patients are never told about them. Knowing them before a discharge dispute gives you leverage that disappears after you have already left.
You have the right to remain in the hospital if you believe discharge is unsafe. You cannot be billed for appealing.
Under the Medicare Beneficiary Notice of Non-Coverage rules, you have the right to appeal any discharge you believe is premature or unsafe. While a formal QIO appeal is pending, Medicare continues to cover your hospital stay and you cannot be charged for those days. This protection applies while you are still in the hospital and the appeal is active.
The Important Message from Medicare (IM) is a notice that hospitals are required to give to Medicare patients near the beginning of their stay and again within two days of discharge. It explains your discharge rights, including your right to appeal and the contact information for your BFCC-QIO.
If you have not received the Important Message from Medicare, ask for it. If a discharge is planned and you have not received it, the hospital is out of compliance and the discharge process should not proceed until it has been delivered and you have had time to read it.
You are required to sign the IM, but signing only acknowledges receipt - it does not mean you agree the discharge is appropriate or that you waive your right to appeal.
Original Medicare: Yes. The hospital can provide a list of certified facilities and agencies but cannot require you to use any specific one. You can choose any Medicare-certified skilled nursing facility or home health agency. Ask the case manager for the complete list of certified options in your area and use Medicare's Care Compare at medicare.gov to check ratings and staffing before deciding.
Medicare Advantage: You must use in-network providers. Ask the case manager to provide the list of in-network SNFs and agencies covered by your specific plan. Verify directly with your plan before committing to any facility.
Be aware that case managers often have preferred referral relationships with certain facilities. That is legal. You are simply not required to follow the recommendation. A facility that received the recommendation because of a relationship with the hospital is not necessarily the best fit for the patient.
Topic three
Appealing an unsafe discharge
If you believe a discharge is premature or unsafe, you can stop it. The window to act is narrow. Here is the exact process.
You must contact the QIO by noon the calendar day after you receive the discharge notice. Act immediately.
The formal appeal window is short. If you receive a discharge notice today, you must contact the BFCC-QIO by noon tomorrow. Do not wait to see if things resolve on their own. Contact the QIO first and continue discussing with the clinical team simultaneously.
1
Call your BFCC-QIO - the number is on your Important Message from Medicare
You can also call 1-800-MEDICARE to be connected. Tell them you want to file an appeal of a planned hospital discharge. Have your Medicare number, the hospital name, and the planned discharge date ready.
2
The hospital is notified and cannot discharge you while the appeal is active
Once the QIO accepts your appeal, it notifies the hospital. Medicare covers continued care during the review period and you cannot be billed for those days. The hospital cannot discharge you while the QIO review is pending.
3
Prepare a written statement explaining why you believe discharge is unsafe
The QIO will give you the opportunity to submit a written statement. Be specific: what symptoms remain unresolved, what functional limitations prevent safe discharge, what services are not yet in place, and what a physician told you about your readiness. Specific clinical observations carry more weight than general statements.
4
The QIO issues a determination, usually within one business day
If the QIO agrees the discharge is premature, coverage continues. If the QIO upholds the discharge, you have the right to leave or remain at your own expense - and the right to continue the appeal through formal written levels including an ALJ hearing.
Topic four
Choosing where you go next
The three main post-acute options each serve different clinical needs and carry different coverage and cost implications. The right choice depends on the patient's clinical situation, not the hospital's preferred referral.
A skilled nursing facility provides rehabilitation - physical, occupational, and speech therapy - multiple times per day alongside 24-hour nursing supervision. Appropriate when recovery requires more support than can be safely provided at home with periodic skilled visits.
Medicare coverage: Fully covered for days 1 through 20 after a qualifying 3-night inpatient hospital stay. Days 21 through 100 have a daily coinsurance ($209.50 in 2025). After day 100, Medicare stops paying entirely. Coverage ends when skilled need ends, not when recovery is complete.
What to ask before accepting a placement: Is this facility currently in-network for my plan? What are its Medicare star ratings for health inspections, staffing, and quality measures? Is it accepting new Medicare admissions right now? Can I visit before committing?
Use Medicare's Care Compare at medicare.gov to check ratings, inspect staffing levels, and review recent health inspection results before deciding.
An inpatient rehabilitation facility (IRF) provides intensive therapy - at least three hours per day, five days per week. IRFs are appropriate for specific diagnoses including stroke, hip fracture, traumatic brain injury, spinal cord injury, and neurological conditions. Not every patient qualifies clinically.
Medicare coverage: Covered under Part A after a qualifying hospital stay. There is a separate IRF benefit period with its own cost-sharing structure. Prior authorization is required under Medicare Advantage.
IRF vs. SNF: IRF provides more intensive therapy but has stricter admission criteria. A patient who is medically stable and can tolerate three or more hours of therapy per day may benefit more from IRF. A patient who is not yet medically stable enough for that intensity will generally go to a SNF first.
Medicare home health covers skilled nursing visits, physical and occupational therapy, and speech therapy at home. No prior hospital stay is required - just a physician order, homebound status, and a skilled care need. No daily cost-sharing for the patient.
Home health is appropriate when the patient's care needs can be safely managed with periodic skilled visits rather than around-the-clock supervision. The clinical team's assessment of safe discharge to home involves the patient's functional level, the physical home environment, and what support is available from family or caregivers.
The important limitation: Home health covers skilled care only. When the skilled need ends - when the wound heals, when therapy goals are met - coverage ends. The daily help with bathing, dressing, and medication management that many patients still need after the skilled period is custodial care, which Medicare does not cover. Plan for this transition before it happens.
Topic five
Before you leave
Confirm these before anyone leaves the hospital. Verbal assurances that things are "in process" are not the same as confirmed.
1
Written discharge summary in hand
The discharge summary documents the diagnosis, what happened during the stay, medication changes, and follow-up instructions. Ask for it in writing before you leave. If you cannot understand something in it, ask a nurse or the attending to explain.
2
Equipment supplier confirmed with a delivery date
If any equipment was ordered - a hospital bed, wheelchair, walker, oxygen, CPAP - confirm the supplier name, a direct contact number, and the confirmed delivery date. Equipment ordered the morning of discharge often does not arrive same day. If you need the equipment to be safely at home, it should be there before you leave.
3
SNF or home health confirmed - not just referred
"A referral has been sent" is not the same as "a bed is confirmed" or "a start-of-care date is scheduled." Confirm the facility has a bed reserved for today's date, or that the home health agency has scheduled the first nursing visit with a specific date and time. Get a contact name and direct phone number for each.
4
Follow-up appointment actually scheduled
"Follow up with your doctor in one week" is an instruction, not an appointment. Ask whether the hospital has scheduled the appointment or whether you need to call to schedule it yourself. For patients at high readmission risk, many hospitals have care transition programs that follow up by phone within 48 to 72 hours.
5
Medications in hand or confirmed filled
Medication changes made during a hospital stay are one of the most common sources of post-discharge problems. Confirm that all new or changed prescriptions have been sent to your pharmacy and that you or your caregiver knows what changed, what the dosing is, and what to watch for.
About the figures on this page.
Dollar amounts and program thresholds reflect published 2025 rates from the Centers for Medicare & Medicaid Services (CMS) and the Social Security Administration (SSA). CMS adjusts most figures annually, typically in the fall before each coverage year. Verify current rates at
medicare.gov
or
ssa.gov
before making enrollment or coverage decisions.
Project Kos is an educational resource. Nothing on this page is legal, financial, or medical advice.
