GardenArtist Asked September 2015
Appealing a doctor's decision to discharge. Any advice?
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Has anyone had any experience with appealing to Medicare under the provision allowing such an appeal when the patient or authorized party disagrees with a doctor's decision to discharge?
The PCP has decided to discharge my father tomorrow even though he (a) can't stand (b) has heart rate, BP, and SAT rate that are higher than normal, (c) lives alone (d) won't get any home care until the day following discharge?
I intend to call the Medicare specified contractor tomorrow to appeal the decision, but honestly expect a runaround or support of the doctor's irresponsible decision.
Anyone have any experience with this short term rapid appeal process?
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Thanks for any suggestions.
I know what you mean about getting caregivers out to the house. The agency I use need 24 hour notice and they charge 1.5x for the first day because everything is so last minute. So I had to stay over with my Dad at my parents house one night and got maybe one hour of sleep because I don't have the strength to help Dad upstairs.
I tell ya, I really hate what my parents are putting me through. It wasn't a life well planned on their part. They should have been in independent living or assisted living years ago.
Wouldn't a second opinion from a specialist be faster?
Also, you are correct to disagree, because if a patient has pneumonia, they have a fever, isn't hospital protocol that a patient should not be discharged with fever, or was that back in the olden-days of proper medical care?
Is hospice involved?
OR, you can call the doctor, inform him/her of the missing details.
Call the hospital administrator next.
GA, you are there or caregiving from a distance?
We had a similar situation once when Dad was rehabbing after his first femur fracture. The Alpha Male director of rehab wanted to discharge Dad right about the 30th day of his stay. Dad was a bit uncomfortable being on his own and wanted to stay another week, but Mr. Alpha Male wouldn't back down.
There was an interesting tete-a-tete in which my father opined on "educated idiots", which I agreed without saying it that the rehab director was one. He definitely was a paper pusher and not a hands on person. I figure he was the relative of someone in high places and that's how he got his job.
Still, he refused to change his discharge Dx and Dad came home early, with much anxiety.
GSA,
I will Google the right to fast appeal info as soon as I post here. Fortunately, Medicare does make it easy with the notice that's provided on admission. So I do have all the data and contact numbers.
But I also know that Medicare doesn't honor its appellate practices. So I don't know how realistically they handle urgent appeals.
I've appealed a hospital price gouging med list for an "observational" stay, and discovered that Medicare doesn't even bother after a preliminary appeal decision.
There is a second level; Medicare just wrote and asked if we wanted to continue the appeal; I wrote and responded yes (replied by cert. mail) but Medicare never did anything else. Never heard from them on the issue again.
Also, the "care in place" will be visiting home care, but that's only 2 - 3x weekly, and only for an hour or so more. It's not 24/7 care. I was surprised the discharge planner didn't raise that issue; instead she wanted to give me one of those advertising booklets listing dozens of AL, IL and other facilities.
When in doubt, hand out free literature!
You hit on a good point though - it was a Eureka! moment when I read it. In the past nurses have told me that Dad tells them what good care I provide for him. (I think he just likes to brag!) I'll bet he did that again and they assumed that we live together and I provide in-home care for him, notwithstanding the fact that the ER doctor, the admitting intern and one of the nurses were all told that he lives alone.
I'm wondering what I can do to convince them that Dad would be in an "unsafe" environment if home alone. This happened the last time this PCP was handling Dad's case and one of the nurses told me I had better plan to stay with him overnight. I asked "where"? There's no room at his house. I can't bring him to mind and lug an oxygen concentrator in the care and we were never given enough tanks from the then supplier.
Dad's plan was to return home and start walking immediately, as he did up until the day he deteriorated and we ended up in ER. My plan was to go to the place he rehabbed after his 2 femur fractures. He liked it, they liked him, the PT and OT were great, as was the food.
But he's refusing to go. I think this is going to have to change as I'm going to have to refuse to participate if he won't agree to the best option available.
If I refused to take him home, one of his church friends would. I thought about refusing, and it's also something I would really hate to do - it's like abandoning him and would really crush his spirit if he though I was in fact abandoning him.
I will refuse to sign the Discharge Orders and will advise Dad to do so as well.
SendMe,
One of the things I've learned is that this PCP business can be a burden when it comes to hospital admissions. Before, I would state we had no PCP (because I honestly don't think much of the field), but decided to "play the game" and stated that this particular one, who we saw a few times, was the PCP.
What I've learned is that if I say there is no PCP, the hospitalist team will be involved. And they're really, really terrific. They're a young group of go-getter, highly knowledgeable and teamwork oriented doctors.
That's what I'm doing tomorrow - calling the hospital to find out how to release the PCP and get the hospitalists on board.
I was in fact somewhat annoyed that the PCP hadn't even consulted the cardiologist about the elevated heart rate.
No, hospice isn't even on the horizon. Even at almost 97, Dad still walks with his rollator about 300 - 400 ft to the lake when the weather is nice.
Re your second post: I'm thinking maybe the PCP doesn't even want to be involved and is just pushing Dad out b/c Dad hasn't been to see him in 1.5 years, and he might not even want an oldster for a patient.
I caregive from a distance, about 27 miles.
And I'm adding the DON on my list of people to talk to. Never thought of the DON - good suggestion.
Answering your question, the doctor who wants to shoo Dad out the door is the PCP we've seen a few times. He's not a doctor we go to on a regular basis. And we've had disagreements in the past when he wanted Dad to take Fosamax, which Dad had taken some years before and found the side effects too unpleasant. The doctor said "he HAS to be on something!" Yet never did he even mention the benefits of weight-bearing exercise for osteoporosis prevention.
That attitude is one of the reasons we never went back.
That's a great idea to involve the Pulmonary physician; Dad's treated with her for years; perhaps she'll even take over the case. And she's really a great doctor.
I think I've answered all your suggestions, and noted them in my phone log for the next phase.
I was even thinking of renting a motel room for the night, but we don't have enough portable oxygen and there's no way I can even haul the larger concentrator out the door.
Guess I'm going to have to bribe my father to go to the rehab facility, if even just for a week.
https://www.medicare.gov/claims-and-appeals/right-to-fast-appeal/hospital/fast-appeals-in-hospitals.html
I have thought of refusing to take him home, but honestly don’t have the will or nerve to do it. It would hurt my father so much; he’d feel as if he was being abandoned. I would probably cry all day and end up going to the hospital to get him.
The issue of a rehab facility was raised, and the Discharge Planner was amenable to considering it. But my father refuses to go. Even a week would make a big difference. We’ve already decided to use the home care agency we had earlier this year; they were very good and contact has already been made. They’ll be on board the day after his discharge, but that still leaves the evening of the discharge day.
The Discharge Planner did tell me that even if he does go home, he can go into a rehab facility within 30 days, which surprised me. I thought that had to be a direct hospital to rehab facility transfer. The DPs have made mistakes before though, so I’d call Medicare to verify that.
My father is adamant that he is going to die in his own home. We’ve discussed this for years, and he will not reconsider. So I’ve accepted it. And I think he would be happier to die near his beloved wood shop than in a facility.
When my dad was sick years ago and looked like he was going to die we took him to the ER but he was released said to make appt with PCP which we did. PCP said let him rest and bring him back in three weeks. I lost it and said look at this man who has been your patient too long for you to have that answer. I know he's a pain in the butt but you can clearly see he is not well. I said never mind I'll take him to another ER and see what they say. And when they ask I'll let them know by name you were the one who refused to have him tested and admitted. He quickly changed his mind and found out he had a blocked prostate issue where he couldn't urinate. The urologist said three more days he would have died. You now have a plan in place, but I was going to suggest you take him to another hospital if it seemed like a viable option at this point.
Check behind the discharge planner. I was told a similar thing back in April when my dad was in the hospital again for a different issue and ran into an issue with it. As long as his PCP approves and you have it in writing before you leave you will be fine. But please make sure you get it then.
I'm not sure what you mean to "check behind the discharge planner." This is not a group with which I'm particularly impressed, so I approach them as I might as porcupine ready to extend its quills. I even try to thank them when they provide me with basic information I already have. "Stroking" plays a big part of deaing with discharge planners.
Update on my situation: things have resolved well and are moving forward; I've been on the phone literally since about 8:30 and just ate while sitting by the phone.
More details later, for anyone else who has to face this. Now it's time for a nice nap.
After 18 months in the hospital following spinal surgery error, leg amputation, etc. this patient would have died of infection going to rehab early.
THE FEVER, pneumonia may be key. These medical incompetents are not aware of people @97 wanting to live!
I dug to the bottom of the issues and discovered what appear to be conflicting stories, but I did make a lot of progress this morning. The alleged discharge order was never written or signed. There's some confusion but I'm going to take a "between the horns of the bull" position and write a letter to someone in admin suggesting that it would be helpful if discharge plans be clarified in the charts before advising patient's families. This seems to be the crux of the issue.
I don't intend to start or get involved in personnel feuds, so I want to take the position that as a patient's relative, I see some areas in which improvement could be made to enhance the already excellent care provided to patients.
At this time there are still some issues with the vitals but I understand more (from a relative in medicine) how they interrelate. Discharge date is only being now discussed as "when" it happens.
I'll write more later when I get caught up on my sanity and sleep.
And I really, really do appreciate the concern of each of you as well as your suggestions and support.
It was one of the few times I lost my patience. I asked if she thought I really had all this time on my hands, running to hospitals, losing work days, not caring for my husband with serious cardiac issues. I told her we had to get the problem FIXED so that she could get back to leading a semi normal life.
She never complained about my handling of her medical issues after that. Sometimes you have to stand up for YOU as well as for the patient.
I've encountered the "family do it all" attitude, found it insulting and irresponsible. I guess working for attorneys for years made me a tough old bird, although sometimes I'm actually a softie.
We made a lot of progress yesterday, I'm switching focus today to planning a small birthday celebration tomorrow, but will have my guard up for those voracious discharge planners who want to gobble up my energy and resistance.
I'm also moving past the "who said, who did or didn't do what" issue with regard to the discharge. There were clearly some issues, but I'm going to step out and leave that to the hospital staff to deal with.
PCP - lots to say about that but I'll hold my wicked tongue until it's been tempered by some chocolate, which I ran out of last night in my frustration.
This is my dilemma for today - how to get a bakery to make a birthday cake with a model of a B-29 when they won't deal with making designs from any copyrighted material. That's a new one on me.
Thanks, everyone. I really appreciate the support and suggestions.