Appealing a doctor's decision to discharge. Any advice?

I would not wait for Dr. Appts but call now and make them aware of changes. I hate when doctors who don't know my husband or Mom make changes of the doctors they see.

I still want to respond to individual suggestions, but also just wanted to provide another update as well as resolution of a few issues, and insight into the complexities of another. Perhaps some of these experiences will help others who might find themselves in similar positions.

We often have to navigate the complex hills, valleys, floods and deserts of medical treatment without much guidance, let alone a map. And GPS doesn't operate for medical routes!

1. I think the error in not calling me to advise of the discharge might have been due to a new discharge planner, too many patients to handle, or other issues. People make mistakes, so I’m chalking it up to that but still making suggestions that it be charted or something else done to double check so that a mistake in not calling a patient’s family for discharge notification can be caught by someone else. Redundancy can help in reducing this kind of what possibly was just human error.

2. We’ve resolved one of the medical issues ourselves, made our decisions and moved on. It’s now past tense. But the decision was made by my father and me as to his best interests, short and long term, factoring in hospital recommendations as well as the fact that decisions were made during acute conditions which have already changed since he’s been home.

3. I’ve learned from another medical provider that the “quick in, quick out” philosophy applies even more now based on Medicare positions. So as soon as the criteria for controlling and/or improving, but not necessarily completely curing, the diagnosis/diagnoses are met, the exit door is the next destination.

I haven’t researched Medicare regs but suspect that this also applies to certain diagnoses, and perhaps not all diagnoses. It may even be an unwritten rule which providers adhere to but isn’t made public for patients.

So I'll be prepare for unanticipated, early discharges and from now on will just automatically carry oxygen in the car!

4. A dozen or so years ago, my father wouldn’t have been discharged while still battling pneumonia. Based on information and my understanding of it, that has changed to the criteria of when a patient is RESPONDING to treatment, but not necessarily cured of the pneumonia.

Apparently this is the new norm for Medicare patients.

5. The issue of the medicine change which was of such concern I now understand is an issue of balance. Based on information from one of our other medical providers as well as some research I’ve done, the choice to D/C warfarin and increase the aspirin dose is based on a sliding scale of offset issues.

6. Someone with A-fib who is younger and less likely to be injured in a fall understandably might be a safer candidate for anticoagulation therapy than someone in his/her 80’s or 90’s or even 100’s with a higher fall potential. Age is definitely a factor, as well as other factors, such as hypertension and diabetes, in determining the choice of anticoagulation meds and aspirin vs. just aspirin.

As fall risk increases, the danger of bleeding from a fall involving head trauma can also increase, becoming more of an important factor in balancing the risk of stroke (b/c of A-fib and anticoagulation ) vs. hemorrhaging.

If falling and possible brain hemorrhage is a greater risk, the anticoagulation is D’C’ed.

However, there is also some good research I found indicating that the risk is greater for stroke, than for internal bleeding after a fall, and that anticoagulation therapy shouldn’t be D'C'ed.

7. So it’s apparently an issue of what the physician believes, without necessarily consulting a cardiologist, as was the case in my father’s situation. I understand now why the hospitalist did what he did, although I think he should have consulted the treating cardiologist, which didn’t happen.

8. The issue of hospitalists vs. private practice doctors is an interesting and apparently evolving one. A medical professional told me that hospitals have more control over hospitalists, rounds can be made at more predictable times, etc. But they don't treat privately, so there's no continuity of care that would exist if a specialist or a PCP were the attending physician during hospitalization.

That means the hospitalist really doesn't know the patient or his or her attitude toward medicine, toward exercise, healing, family involvement and other important issues.

Perhaps it's the old question whether a physician treats the illness or treats the patient.


Sometime during a nice windy, blustery fall day (which isn't far off) I'll do some research just out of curiosity to see if there are other issues in this hospitalist vs. private care doctor situation.


My father is improving, at a faster rate than he initially did in the hospital (sure helps to be in one's comfortable chair, in comfortable clothing and wrapped up in warm cozy blankets!), so in retrospect I’m glad he was discharged when he was.

Still, this has been another learning experience. I’m starting my own manual of questions and answers in a database so I can quickly figure out what the hospital might be doing if Dad is hospitalized again with similar diagnoses.

I really do hope our experiences will help others, as sometimes doctors and hospitals can operate in mysterious ways.

Thanks again to everyone, and if I don't get back to respond to each of you, I really do appreciate your advice and assistance.

GA, this helps tremendously. You mentioned a few things I can recall with one of my parents at some point in time. I'm sorry you had to go through all of this, but thank you for the time and detail you've outlined here. I too, have started a doc of posts as I've run into some brilliant answers on here on various topics that I want to have on hand when needed. All the best to you and dad.

GardenArtist, regarding the warfarin, my Dad was on that after he had a heart attack... couple years later he became a fall risk and one time broke his nose and couldn't stop the bleeding... it was then that the doctor decided to take him off of warfarin. His falls make him too much of a risk of bleeding to death. It was a good decision.

JoAnn, I agree - I resent it when someone who doesn't know my father presumes to makes decisions without even getting to know him as a person.

JB, thanks; I'm glad that my post was of help. You're right - there are a lot of good answers here to save for future reference.

FF, I'm hoping your father hasn't had any heart attacks since going off Warfarin?

It's interesting and sometimes frightening how many issues arise and interact with each other as we age.

(I'm trying to think of a way to write a book on all these experiences in a funny manner - maybe it would support me in my old age. Oh, wait, I'm already old!)

Just learned of another incident which provoked some of the friction which I later realized developed between the hospitalist and my father, who is one of those people who pushes for as much mobility as he can while aging. (He began a major construction project in his 80's, and just doesn't give up.) He's my Energizer Father (without the pink ears, drum, and lots of banging on the drum.)

Well, Dr. No Bedside Manners as I've now named him became annoyed when Dad challenged that he would be on oxygen for the rest of his life, then treated Dad like a child. (Dad was told 12 years ago he was in a terminal condition, but IF he did live he'd never walk again or get off a ventilator).

Dr. NBM became annoyed at Dad's response to having to use oxygen 24/7 at home, turned to Dad's visitors, and advised him on the situation, completely ignoring my father as if he were still a child.

How rude! It's probably a good thing I wasn't there or my response meter and protectiveness index might have soared off the chart. Treating my father as if he wasn't there was inexcusable.

It reminded me then that hospitalists might not be such a good idea if they don't have a lot of patient experience, and OLDER PATIENT experience. Without a practice outside of hospital rounds, they won't get to know the patient and his/her personality as they would if they treated the patient before and/or after hospitalization. Another conundrum for the medical pros to work out.

Here it is 2017, and I am reading these pearls of wisdom and experience on behalf of a loved one (actually two) who need this kind of information and help.
It takes a lot of time, and reading to understand, but I will be doing my best to pass this info on to the person (or persons) in the family who seem to be in charge. (OR NOT IN CHARGE! so far!) No details to protect the guilty, but I may have to call in some help in the form of APS to kick sum butt!

Gearing up to go over their heads.

Have you looked into a Skilled Nursing Facility for a short term rehab stay? You can do an expedited appeal to Medicare, and may win.

This happened to me years ago after major life-saving surgery. I was very ill, running a high fever, in bad shape - doctor released me. My husband fought with the hospital and the doctor's ruling was overturned -and I stayed in the hospital until I was well enough to leave. The doctor was furious but I then immediately sought another doctor. Don't take this - fight back with all the guns you can muster. This is serious. Seek other top professional opinions.

sophe509 wrote this a year ago, but it's such good advice! "...what has worked for me in the past is notifying via fax the hospital social worker assigned to his case, the nurse unit manager and the physician that this man lives alone and that they are discharging him to live alone. They bear the responsibility for whatever happens to him. You are going to be out of town. Ask for an occupational therapist to do a home safety evaluation and report prior to discharge. Do not offer to pick him up, do not be available by phone. Insist on all communications in writing. Appear as though you are getting ready to sue their sorry a$$es and they will perk up and behave. (hopefully)."

Regarding warfarin for elders with fall risk -- My mother has a-fib and is on both warfarin and baby aspirin. She has a cerebral aneurysm. The neurologist didn't want her on both warfarin and baby aspirin, but the cardiologist did and overruled the neurologist. My mother has bad balance, and although she hasn't fallen yet, she is a fall risk. (She has no sight in one eye, horrible depth perception, sometimes gets a feeling that is somewhere between dizziness and panicky.)

A fast appeal re discharge is different than other types of medicare appeal. See page 107 in Medicare & You handbook ! The hospital should have provided you with a notice and the name and contact # for your BeneficiRy and Family Centered Care Quity Improvement Organization. In Northern California it is Livanta. Call them immediately they wi typically put a hold on the discharge and send in an independent agent to review the patients case . This may take three dYs allowing the patient to remain in the bospitL pending. If they determine e he could be have been safely released he may be responsible for hospital charges. This worked for a family friend recently!!!!

Yes, but I didn't have to contact Medicare - I simply refused to allow my father to be discharged before he felt he was ready.

The doctor came in and pretty much said, what the heck?! I said, my father does not feel he is ready to go home. Now the doctor spoke with my dad and asked him why. My dad was allowed to stay the extra day and then he decided he was ready and was discharged.

Patients have rights and there are people within the hospital you can contact for just this scenario. Patient Advocates.

I know this question was posed 2 years ago, but if anyone is still reading the answers this could help them... I absolutely do know about the right to appeal a "planned" discharge deemed by family (POA, etc.) as premature or unsafe. Also, it seems there is some confusion about the Medicare "100 days" rule... My Mom, 95 at the time, fell & broke her hip and wrist. She had successful surgery, but was injured (her feet, another story!) by the first "rehab/skilled nursing" facility she went to from the hospital. Within one week, (with POA and Medical POA) I jerked her out of that abusive situation and had her transferred to a different facility. They were caring, competent, but the damage to my Mom's feet was so severe she required wound care and dressings every other day, and was on narcotic pain meds for a long time. She was seriously hurt and mentally confused from the trauma of her medical situation and Percocet every 4 hours. Mom had never signed up for Medicare Part B when she retired in the 60's (this IS an option, although at the time of Mom's retirement it was not explained and she didn't realize the ultimate implications). Medicare Part A, which provides coverage without cost for anyone who paid into Social Security, kicks in for in-hospital care and skilled nursing/rehab following discharge from the hospital. The MAXIMUM Part A coverage is 100 days post-hospital. The length of coverage is determined by measurable medical and/or rehab progress. The first 20 days are covered at 100%, but the potential 80 days remaining require a copay (2 years ago Mom's was $157.00/day). (A lot of money, but far less than the cost without Medicare for the same services/facilities.) Mom did have good private insurance, but because she didn't have M. Part B, this is where her situation got dire... She had to pay co-pays, MediVans for doctors' appointments (BTW, these are NOT covered for anyone by insurance), many costs that would have been covered by "Primary - Part B - coverage". Everything was out of pocket, and her compulsively hoarded savings were quickly dwindling. (She was a survivor of the "Great Depression" and was terrified of not having a nest egg to fall back on. She deprived herself of many pleasures in life to save-save-save!) Now, so much for that! The facility (social services office) dictated a planned discharge date early on in her stay (20-30 days?), citing as a reason that she wasn't making measurable progress in physical therapy. I'd heard that same day from one of her therapists that she was doing well, and challenged the discharge. You should be provided a page explaining patients' rights to appeal with Medicare, and I was required to sign an understanding of the discharge and options. I DID appeal! A simple phone call to the number listed kicked the appeal into place, and automatically guaranteed at least a 24-hour stay on the discharge. A review was then conducted by Medicare medical experts of her entire medical file and current conditions. They provide a decision within 24-48 hours, with costs remaining covered, until their decision to agree with the facility's discharge plan or their denial. Mom's appeal was approved, with Medicare agreeing with me that it was premature to discharge her. From that point, she had to be periodically evaluated for discharge eligibility, and each time they set a new date the same option to appeal existed. I made several more appeals, which were upheld, until she had used approximately 85 of her 100 days of coverage... She was then moved down to a lesser level of care section in the facility, and all costs (about $8,000/month) were payable from her pocket... Her orthopedic doc stated that he believed with rehab she could regain the level of mobility she had before her fall, and ordered she receive that rehab... That entailed moving her back to the higher-level of skilled nursing/rehab, and also kicked Medicare Part A coverage back in play... Finally, without about 94 days of the 100 used, she was deemed able to move to assisted living (with a LOT of help!), and was discharged to an AL location I chose... She had an acute medical condition arise after about 3 weeks there, returned to the hospital (covered by Part A),

Yes you have a right to appeal a discharge with Medicare ,,their are actually 5 steps to,a appeal ...first the appeal when you tell the case manger you want to appeal the discharge , then you can also reappeal by calling and talking to them , the next step goes to a judge to decide ,, I don't know the last 2 steps ...

I already answered this so I deleted my comments.  2 months ago.

I'm late to the party to thank you Garde Artist so thank you for your comment.

Just a note per some of the answers/information given here (i.e., for example about 5 steps? Case manager/judge, etc.?) Unless it differs from state to state, all that is necessary is that you call the medicare number on the form that should be given to you with the info about the planned discharge and say you want to challenge the discharge. (You can also tell the "case manager", or social services people you're probably dealing with, but in my case that was just a "you need to know I have appealed the discharge with Medicare" (there is a specific company that usually handles this, but it is under Medicare's direction and that is the number given to call...). I didn't ask permission - or discuss the situation with any hospital personnel or doctors - just called the Medicare appeals phone number. If the hospital or facility attempting the discharge doesn't automatically provide you with the official information re Medicare appeals and the process, ASK for it! You should actually have to sign acknowledgment of having received it! I appealed on 3 different occasions, and my appeal was upheld on 2. The third was denied, but that still gave me the extra two days I felt my Mom needed to safely (mentally and physically) move to a different facility. The only time you have to pay everything out of pocket is IF Medicare denies the appeal and you fail to comply with the discharge at that point... Even then, you have until noon on the day following Medicare's decision to have the patient moved. Knowledge gives you the strength to stand up to the bureaucracy and system that are only thinking in terms of $$$'s and not in the best interests of your loved ones. 

I have this experience on there every time my mother is in the hospital they discharged your parent I don't know how old they are because they are elderly because they are elderly and they put them in for observation because they didn't do any revelin testing I was told that's all Insurance allows my mother quite recently possibly had a TI a will we know that she did but because the doctor didn't see fit to do imaging and MRI and he put her in under observation he told me yes she probably had a t i a but she's better now and a holler testifying bottom line to health care in this country for the elderly is non-existent my mother has two insurances the second one is very good they don't want to take care of the elderly they want to ask you what the abased line is whether or wether not they have dementia and they just want to tell you it's dementia nine times out of ten as far as my mother is concerned it has been from withdrawal of meds that they took her off even though I gave them the list and told them she could not come off cuz she could die changed her meds which disagreed with her I had a mother who was 100% continent she came home from the hospital she was getting worse every day they would changing her meds incontinent and then she had a t i a and also impacted so that's the experiences I've had from hospitals and I don't know whatever else any of us can do to change it the only thing is if you have your own money and a pretty well-off you can pay for private care you can pay for a week and respite so you can get a break but other than that doctors do not will not do much more for your parent if they seem to be better that's it

By the way they gave us the right to appeal decision paper after she was discharged and out of the hospital as we were walking out which makes a pretty difficult at that point because you don't even have a chance to look at the papers. If I seem better it's because I am because I've screamed and yelled for the last three years trying to be her biggest Advocate because every health professional I talked to told me you had to be with the elderly sick to say this but once again they don't care about the elderly everything is dementia even if they were okay when you brought them there they come out worse than they went in it's been my experience all the time

Helpmequick21 - I totally understand what you're going through - I've been in that situation for 2+ years. My 95-year old Mom lived with me, fell and broke her hip and wrist, and her life descended into H*ll on earth... She was very bright when she fell, although at 95 she was having some minor memory issues, but some of her docs ("primary care") simply put the label senile dementia front and center on her chart, and treated her accordingly (I actually fired a few docs along the way). I was pushy, stubborn, and vocal enough that my Mom has, in fact, received advanced medical care despite her age (she's now 97!) Mom has had serious vascular (circulation) problems for years, and of course, has really skin... She had developed a huge ulcer on top of her foot following damage caused by one of the "skilled nursing" facilities. The original "options" given were for amputation - which she refused - or "palliative/hospice" care. Bless her Vascular Surgeon, who called the next day, asked about her heart and lungs (good), and said he doesn't believe in limiting health care, options, or treatments just because of someone's age, and thought we should try a bypass below her knee... At 96, she made it through a 5 1/2 hour bypass surgery,  although afterwards she was in ICU for 14 days (on a ventilator for 3).  The surgery successfully established circulation and healing of her foot! Sadly, like your Mom, she too was very bright when she was originally injured by a fall at 95, and since then has declined - again, as with your Mom, following several surgeries, anesthesia, extended Percocet use, and just plain shock... Now 97 years old, she's still cognizant most of the time, but lately has been getting confused and her short-term memory has declined... She is, though, receiving Occupational Therapy and Physical Therapy (each 1/x per week) from an outside facility, is improving, and can now get up from a wheelchair to a walker and walk for quite a distance. (Again, though, I had to be very "persuasive" to get therapy approved since she's in a nursing home...!) I hope your Mom improves, and keep advocating for her, although I really understand how frustrating and exhausting that can be... Good luck and bless you for caring!

simple. It's an unsafe discharge. Walk away. Will have to involve social then. Sounds harsh but it's our life too and soooo hard watching them . We shouldn't be in this position.