Medicare Coverage - Are You Being Admitted or "observed?"

Medicare Coverage - Are you being Admitted or "Observed?"

It recently came to my attention that a growing number of Medicare beneficiaries are spending days in the hospital before being transferred to a nursing home, only to find out that Medicare won't pay . . . . .

won't pay for the first 20 days of their nursing home stay, as it typically would. The reason, I found out, is that they had never actually been "admitted" to the hospital, but were only under "observation." A trick!!

Medicare covers nursing home stays entirely for the first 20 days, but only if the patient was first admitted to a hospital as an inpatient for at least 3 days. In part due to pressure from Medicare to reduce costly inpatient stays, hospitals are increasingly not admitting patients bur rather placing them on observation to determine whether they should be admitted.

Although according to Medicare guidelines, it should take no more than 24 to 48 hours to make this determination, in reality hospitals can keep patients under observation for days.

Here's the consequence. If the patient moves to a nursing home after being "released," the patient must pick up the tab for the nursing home stay. Medicare will pay none of it. But hospital patients often have no idea that they haven't actually been admitted to the hospital, and Medicare does not require such notifications.

You go upstairs to a bed, get a band on your wrist, nurses and doctors come to see you, you get treatment and tests, and you even fill out a meal chart, assuming that you have been admitted to the hospital.

In any case, there is little that patients who know they have been placed in observation status can do because they haven't been refused benefits. Medicare is still paying for your hospital stay, although on an outpatient basis.

There's no official appeal that I've found anywhere, as Medicare has not denied coverage. You're in no man's land.

More and more beneficiaries are becoming temporary residents of this no man's land. Medicare claims for observation care rose from 828,000 in 2006 to more than 1.1 million in 2009. Over the same period, Medicare claims for observation care that lasted more than 48 hours tripled to 83,183.

Help is on the way (maybe). Rep. Joe Courtney (Dem-CT) recently introduced a bill, H.R. 5950, that would allow for the time patients spend in the hospital under "observation status" to count toward the requisite 3 day hospital stay for Medicare coverage of skilled nursing care.

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Let's keep our fingers crossed on this one.

http://www.bukisa.com/articles/401783_your-medicare-plan-is-critical-this-year-changes-coming