After suffering an injury, you’re seemingly admitted into a hospital and stay there for a few days. Because of a broken bone or cardiac condition, you’re placed in the care of a nursing facility for further treatment after being discharged.
But then months later, a bill arrives in the mail, stating you owe in the thousands of dollars, all when you thought Medicare would be covering the treatment. So, what happened?
A series of news articles in February, spurred by a warning to seniors, focused on what’s being called “under observation” – that is, what can potentially become multi-day outpatient care for an elderly person that eventually turns into long-term nursing care, all without Medicare coverage.
According to a piece from the Columbus Dispatch, hospitals began increasing this practice – marking a Medicare-insured patient as “under observation,” instead of “inpatient,” for a multi-night hospital stay – as the result of pressure from insurance companies.
As the piece explains, Medicare reduces a hospital’s payments if readmission rates are too high. Patients, however, end up getting monitored, tested, and treated, staying in a facility for at least two days, assuming a doctor officially admitted them.
From here, patients not marked as “inpatient” for their hospital treatments do not qualify for Medicare’s help when nursing home aftercare becomes needed.
The process typically works that once a patient gets admitted as “inpatient,” Medicare Part A covers all costs under a one-time deductable of $1,216, up to 60 days. As a patient is in the hospital with three days of “inpatient” care, Medicare Part B pays 80 percent of the doctor’s services; the patient is responsible for the rest. After this period, Medicare pays for 20 days of care in an approved facility.
If a patient is admitted as “under observation,” Medicare Part A pays nothing, but Part B pays for some services. Nursing care, in this instance, is not covered.
As U.S. Rep Joe Courtney pushed for such legislation in 2010, so Medicare patients would be covered for nursing care, the issue hits close to home – so much that case managers have been observing two Connecticut hospitals. Findings show fewer and fewer patients (from one in 10 to one in eight) now meet the criteria to be admitted as “inpatient.”
At the state and federal level, legislatures are requesting changes. The Center for Medicare Advocacy wants all patients to receive notification about their status (currently, only some hospitals do this) and to have the chance to appeal. Other states are attempting to have three days of “under observation” qualify for covered nursing home care.
The federal government, meanwhile, has been considering what’s called the “two midnight” rule – or that any treatment lasting at least two midnights automatically is considered “inpatient.” However, it doesn’t address any aftercare in a nursing home.
What can a patient or family members do in the time being? As a general rule regardless of condition, make sure you ask about the status at least once every day after being admitted.
