How hospitals are avoiding paying Medicare and sticking YOU with the bill.

[dixiegrrrrl]

I found this info from a March posting in the Soc.Sec. Medicare group, and went to the link, and found there is an actual step by step procedure to avoid this problem, which I downloaded as a pdf file to keep.
Original posting here: http://www.democraticunderground.com/1261246....
to Tace.

Ok....this is the problem:
Odds are that you do not know a key question to ask if you ever find yourself in a hospital for an overnight stay that could last from one or two days, or perhaps much more.
What you and anyone accompanying you want to know is whether you are being classified as “under observation.”
This means that legally you are not an inpatient.
If you are admitted as under observation, you are likely to find yourself owing the hospital a large amount of money, because your Medicare or other health insurance will not provide the benefits associated with inpatient status'
. Many, many Americans nationwide that were classified as under observation have faced unexpected bills of many tens of thousands of dollars.

To clarify: Medicare DOES pay for inpatient care, if you are admitted as an "inpatient".
but admission as "under observation" Medicare says is an OUTPATIENT service, and pays much much less.
YOU get billed for the difference.
The hospital comes out ahead because Medicare inpatient coverage is not as high as other insurance, so by listing you as" under observation"
, you have to pay the higher hospital bill, that Medicare did not pay for.


Here is how to avoid the problem:

READ this:http://worldnewstrust.com/medicare-madness-how-americans-can-lose-benefits-in-a-hospital-joel-s-hirschhorn
and
Make a copy of this:http://www.medicareadvocacy.org/self-help-packet-for-medicare-observation-status/

Also note that last link is to a Medicare advocacy group, which could come in handy for a lot of Medicare issues.
There is a lawsuit in the making about the "under observation" rule, btw.

[Downwinder]

1. I don't have that problem. They know if they don't

get it from Medicare, they won't get it!!

[Scuba]

2. Hospitals don't pay Medicare. Medicare pays hospitals.

Hospitals have no financial incentive to classify a Medicare patient as an observation patient. Quite the opposite.

[dixiegrrrrl]

7. Scuba, read the info at the links I provided.

where it clearly states that hospital DO have incentive, and why.

[Scuba]

12. Your first link (back to DU) fails (404 error). The second link includes a piece explaining ...

... how hosptials can be penalized following "Medicare audits that declare patients wrongly defined as inpatients". It also describes how hospitals can be penalized for readmissions within 30 days (wrongly describing that as a "new wrinkle under Obamacare". This was a Medicare quality parameter before I retired in 2008 and hospitals were indeed penalized for it back then.).

The third article is a "self help" guide for patients and .

None of these links describes any way that hospitals have a financial incentive to classify patients who should be inpatients as observation patients. Fact is, Medicare pays and patients often don't. Hospitals like getting paid. If the patient is qualified to be classified as an inpatient, it is advantageous to the hospital to classify them as such.

Obviously, patients that are not qualified to be classified as inpatients should not be admitted.

While it's undoubtedly true that some hospitals may be holding patients in observation status to avoid the 30-day readmission penalty, this is a Medicare violation and getting caught will result in even greater penalties, so there's no legitimate incentive to do so.

There are many legitimate medical reasons for holding patients in observation status, but there are no legitimate financial incentives for doing so. If the patient is qualified for admission the hospital will be paid in full, and quicker, by Medicare than trying to collect from the patient.

Finally, if a hospital changes patient status from observation (outpatient) to inpatient when the patient's condition doesn't warrant an admission, the hospital can incur Medicare penalties for that inappropriate admission.

[alfie]

3. It isn't as scary as it sounds

I graduated from nursing school in 1975 and shortly after that became aware of a lot of the Medicare billing issues. As the link for medicareadvocacy.org states, the observation status does figure in if a patient needs skilled nursing care after they are discharged. Medicare has required a "three day qualifying hosptal stay" in order to qualify for skilled nursing care since at least 1975 that I know of.

Now, to understand the difference between observation and inpatient....the observation status is usually used when a patient from ER is too unstable to go home but doesn't require inpatient care for a prolonged time. For instance, our town had a stomach virus that swept through several years ago. The ER was flooded. For youngish folks, a liter of fluids, some anti-nausea meds, a trial on clear liquids by mouth was enough to send them home with follow up instructions. But for unstable diabetics, the elderly, or chronically ill folks, this was not enough. We admitted most of them to observation. Most were stabalized during the observation period, if not they were admitted as inpatients. They would not have needed to be sent to a nursing home for skilled nursing care.

Skilled nursing care is justified for patients who pretty much required a prolonged hospitalization, easily making the 3 day qualifying hospital stay. This patients usually are recovering from orthopedic surgery such as hip replacements, or strokes where they need follow-up inpatient PT and/or OT. In other cases they have wounds that need daily or more frequent dressing changes and assessments by nurses. There are many other examples. The bottom line is that these patents were seriously ill or injured in the first place that the 3 days inpatient stay would have happened.

For short term observation stays, if a patient has Medicare Part B, and especially has a Medicare gap insurance policy, most if not all of the care will be paid for. No hospital will try to trick a patient into being "self pay".

[dixiegrrrrl]

6. Your comments suggest that you did not read all of the info at the links I provided.

It was the info which prompted me to post this.

[alfie]

10. I'm not sure what part of your links you are referring to

I have re-read both links. Maybe you could be more specific.

Maybe my hospital was the exception, but everyone involved understood when patients were observation and what that meant. A sticker was on the front of the chart to remind the doctor when the observation period would end so he/she could discharge the patient or change their status to inpatient. The patient's family were asked to bring in their home meds so we could administer them from their supply without charge vs having to charge them for drugs from the pharmacy. Drugs such as IV drugs would be paid by Medicare B, as would lab and MD fees.

[GeorgeGist]

4. The doctors are in on it.

Wonder how they get reimbursed?

[rurallib]

5. Thank you so much

going in for a procedure in a couple of weeks and this may be really helpful.

[dixiegrrrrl]

8. The other bit I learned the hard way was

Mr. dixie went in for a collapsed lung. He has Medciare A but did not have B.
The dr. bills, and the 3 x daily chest x-rays
were classified as "outpatient" expenses, not covered under A.
in fact, A only really covers nursing and a bed, and maybe some meds.
Plus A has the 1500.00 deduct.
We had to pay the 800.00 ER bill
and all of the doc bills
and all of the x-rays.
The only bright spot was medical bills in our small town are not the horror they are in larger areas
and the hospital will let you pay it off, interest free.

[rurallib]

9. glad I had a chance to learn from you!

[dixiegrrrrl]

11. the other thing to watch for

has made headlines of late.
It's called drive-by doctoring.
It is when a doc you don't t know, have not even met most likely, peeks into your room, asks how you are doing, disappears, and then you get a bill from him.
This actually happened with Mr. Dixie.
I, the keeper of the purse, found the charge on the bills, and got in touch with our insurance company.
They refused to pay.
We refused to pay.
The doctor yelled.
I asked him to provide us a list of itemized charges for his 1200.00 bill, or else.
He couldn't.
Gogle drive by doctor, and see.

There is a variation on that.
You have an operation.
The hospital calls in an out of network doc for something to do with the operation, like anesthesia, and he bills you.
Insurance won't pay for out of network.
So it pays to sit down with the hospital before an operation, if possible, and ask which staff they will be using, and what the average non-complicattions cost would be.
Hospitals are not used to doing that, btw....but they can be trained.