How Medicare handles its observed patients
February 19, 2017
By: Mark Harvey
Email: harvemb@dshs.wa.gov
This is about Medicare.
If you’re not on Medicare, not about to be and don’t know or like anyone who is, this won’t touch you; although, it might tickle your inquiring mind…We’ll see.
We’ve talked about this before – “This” being the fact that, under Medicare, any of us could be in the hospital, sleeping in a hospital bed, eating hospital food, being treated and attended to by hospital people, etc. ad infinitum, but…NOT being “admitted.”
We just thought we’d been admitted because of all of the above; actually, we were being “observed.”
Let’s back up.
Under current Medicare regulations, a person who is hospitalized and then requires some time in a skilled nursing facility (think, rehab), will only have that skilled nursing facility time paid for by Medicare IF they’d spent three days (well, OK, three nights, but I don’t want to quibble with Medicare wonks) ADMITTED in a hospital; so, if you’re being OBSERVED in a hospital, Medicare doesn’t pay for the nursing home time and you get whacked with a MAJOR nursing home bill!
Ouch!
Now, let’s be clear: If you’re hospital “experience” is not one that will require time in a skilled nursing facility (i.e., you’re going home, or wherever), you don’t care – None of this matters – But if you might need time in a facility, you need to care deeply.
“That doesn’t make any sense!” You correctly observe. OF COURSE NOT!
“…then, how can it be?” You reasonably ask. It goes like this:
Some years back, Medicare began contracting with private companies to “audit” hospitals’ (and others) billing practices; interestingly, said private companies are also allowed to keep a percentage of any funds recovered from “improper payments.”
MORE interestingly, said private auditors began concluding that hospitals were admitting patients unnecessarily, when they could have been (should have been) treated on an outpatient basis (which is less expensive), so hospitals had over-charged, SO they’d better pay back that money!
Hospitals were squeezed, so they figured they figured that they’d better start treating more folks as “outpatients,” so – BOOM! You’re being “observed!”
I know. I agree.
What made matters worse was the fact that few-if-any of us realized that we were being observed (well, OK, we probably knew that we were being observed, we just assumed that we’d been admitted), so we went merrily to the facility and rehabbed nicely, only to be put into cardiac arrest by the nursing home bill.
So, what’s come of all this? Well, Congress actually managed to pass a law (I know; me, too) that requires hospitals to provide a notice to “…each individual who receives observation services as an outpatient…” for more than 24 hours. Does that really “solve” the problem? Not in my opinion, but at least it takes the element of surprise out of the equation.
So, what would you do if you got such a notice (remembering that this really only matters if you might be discharged to a nursing facility)? Well, I’d start by talking to my doctor.
In fairness, many (if not most) of our local hospitals have been notifying patients of their status for some time – GOOD FOR THEM! – But that doesn’t mean that we get to stop paying attention; however, there is another problem here. Ready?
Right! Most people who are in hospitals don’t feel very good! Thus, they (WE!) tend to not always be at our usual, alert, attentive and quasi-confrontational BEST: Thus, it falls on those of us who are friends/family/caregivers to pay attention for them, right?
Right.
“Why didn’t Congress just change the **** regulation?” You reasonably ask. Good question. Feel free to contact every Congressperson you can think of and ask it – Repeatedly.
In the meantime, about all we can do is understand the game and try to pay attention…Oh! Wait! I heard that! Some of you are thinking: “Well, I have a Medicare supplemental policy, so that’ll cover it, right?”
Wrong. MediGaps (aka, MedSupps, whatever) only offer coverage (at whatever level) for charges that Medicare APPROVES; so, if Medicare says, “no,” you can imagine what your supplemental policy will say.
So, what’s the real answer? Right: Stay healthy, and forget the whole **** thing!