What's a NODMAR?

If you know anyone who is a Medicare beneficiary in the hospital who will be discharged soon, you should be familiar with a NODMAR.

The Notice of Discharge and Medicare Appeal Rights (NODMAR) document is an important part of the in-patient discharge procedure. Besides having a discharge plan for a patient, hospitals must provide a trained staff member or members, often social workers or nurses, to contact Medicare patients prior to discharge to explain their discharge appeal rights. The NODMAR document is designed to inform Medicare enrollees of their rights when they have received a hospital in-patient discharge decision. Though hospitals may use their own language, the NODMAR document must include three basic elements: (1) the reason in-patient care is no longer needed; (2) the effective date of the enrollee's risk of financial liability; and (3) the enrollee's appeal rights.

Let's say that your mother has been in the hospital for surgery. The admitting physician has now downgraded her condition and determined she no longer needs in-patient care. Shortly after this change in status, the facility will likely send a staff member to discuss the decision with your mother and ask her to sign the NODMAR. If she is alone at the time of the visit, your mom might be hesitant to sign any document without fully understanding its contents. Let's go through the basic features of the NODMAR so you can help to clarify the document.

The first part of the document includes some basic information: your mother's name; her health insurance claim (HIC) number; the attending physician's name; the name of the facility; the date of the notice; the admission date; the discharge date; and the name of your mom's health plan.

The next part of the document provides the reason your mother is being discharged. It states that the admitting physician has reviewed your mother's chart and thinks her medical condition has improved enough such that it has been determined she may be released. Afterwards, a reason for the release is provided. A typical reason is that the physician feels that in-patient hospital care is no longer required and medical care that is needed may be received safely in another setting. The physician may provide other individual reasons. There is mention of the hospital's discharge plan regarding follow-up care, medications and so on, and information on how to contact someone about the specifics.

At this point, the document informs the patient that if she chooses to remain in the hospital, it's likely that her hospital charges that begin on the specific date of the first uncovered date will be charged to her. A statement is made that her health plan (if she has one) will not cover the charges.

Let's pause here a moment, because I want to tell you something very important. If you think your mom is being asked to leave the hospital too soon, Medicare gives you, your mother, an authorized representative, attorney or court appointed guardian, the right to appeal the discharge decision by making a request for an immediate review. While the review is being conducted, your mother may remain in the hospital and her health plan will continue to be responsible for the cost of the stay until noon of the calendar day following the day the peer review organization (PRO-a Medicare authorized review group) notifies you of its official decision.

There are rules, though. The authorized agent must contact the peer review organization by phone or in writing (include name, address, telephone and fax number of the PRO) and the request must be made no later than noon of the first working day after you receive the discharge notice. The PRO makes a decision within one full working day after receiving the request and the patient's pertinent medical information.

If the PRO agrees with the discharge decision, your mother will be responsible for payment beginning at noon of the next calendar day following the day the PRO provides notification of its official decision. If the PRO disagrees with the decision, you will not be responsible for paying for the additional days except for certain convenience services not covered by the health plan.

Basically, your mom has gained approximately 72 hours of grace time that may be needed to make other arrangements. You have until noon the day after your mother receives the discharge notice (day 1), plus the day of the PRO review (day 2), plus up until noon of the next calendar day after the official decision is made (day 3) before your mom has to leave the hospital and before your mom is financially liable.

If you are late or miss the deadline, you may still request an expedited appeal from your health plan, which has to review your request within 72 hours. However, in this case, there is no automatic financial protection for the hospital charges during the course of the appeal.

If you would like a copy of the NODMAR, send a request with a self-addressed stamped envelope to Barbara Zapotocky,DC, 3030 Hibiscus Drive, Honolulu, HI 96815 or go to the following website (http://www.hcfa.gov/medicare/op1082.htm) and download the document. As always, your questions and comments are welcome. Aloha.