Status of Medicare Patients: What You Don't Know Can Cost You!

We have written about this critical issue before and unfortunately, Congress has not corrected the situation. Increasing numbers of Medicare beneficiaries are finding out that Medicare will not cover their post-acute skilled nursing facility stays because they were kept in the hospital for observation rather than being admitted as inpatients.  

As reported in the Boston Globe in late August, the stories of Medicare-eligible Americans who become caught in this technicality are heart breaking. Reported by Liz Kowalczyk:

"Harold Engler recently spent 10 days in a Boston teaching hospital, trying to snap back from complications after urgent hernia surgery. Nurses provided around-the-clock treatment, changing the 91-year-old's catheter, for example, and pumping him with intravenous drugs for suspected pneumonia.

It all seemed like textbook hospital care to his wife, Sylvia. So she was shocked to learn that Beth Israel Deaconess Medical Center had never "admitted" her husband at all.

Mrs. Engler, we have bad news for you. This was marked 'medical observation,' " said a nurse at the nursing home where her husband was sent for rehabilitation. The hospital had decided Harold Engler was not sick enough to qualify as an official "inpatient.

The difference in terminology was not a mere technicality: the observation classification left the Englers with a huge bill. It triggered a mystifying Medicare rule that required the Framingham couple to pay the entire $7,859 cost of his rehabilitation care and the medications he needed while at the nursing facility. If Harold Engler, a retired sales executive, had been admitted to the hospital, they would have likely paid nothing."

What can you do?

If you’re in the hospital more than a few hours, always ask your doctor or the hospital staff if you are an inpatient (you have been admitted) or an outpatient (under observation). If you are under observation for more than 48 hours, ask why you are not being admitted. It is most important that you find out your status before being transferred to a SNF for rehabilitation services. Medicare will only pay for care in a SNF after a 3-day inpatient stay. If you were not admitted, you won’t have the required hospital stay and you will be billed for your time in the nursing home.

What are your rights?

You can ask your doctor to admit you to the hospital, but you cannot mandate it. If you go to a nursing home and later find out that you did not have the 3-day inpatient stay, you can ask the nursing home to bill Medicare for your stay. Although Medicare will likely deny the claim, you will be in a position to appeal the decision. You can also challenge your Medicare Summary Notice when it comes. Follow the guidelines and the deadlines to appeal.

Please share this information with your friends and family.