Medicare rules give full hospital benefits only to those with 'inpatient' status

WaPo ^ | 9/7/10 | Susan Jaffe

[Nachum]

After Ann Callan, 85, fell and broke four ribs, she spent six days at Holy Cross Hospital in Silver Spring. Doctors and nurses examined her daily and gave her medications and oxygen to help her breathe. But when she was discharged in early January, her family got a surprise: Medicare would not pay for her follow-up nursing home care, because she did not have the prerequisite three days of inpatient care.

"Where was she?" asks her husband, Paul Callan, 85, a retired U.S. Army colonel. "I was with her all the time. I knew she was a patient there."

But Holy Cross had admitted her only for observation. Observation services include short-term treatment and tests to help doctors decide if the patient should be admitted for inpatient treatment. Medicare's guidance says it should take no more than 24 to 48 hours to make this determination.

[DallasDeb]

Sounds like the hospital failed to do valid utilization review.

[theDentist]

ahhh ObamaCare.

[listenhillary]

Sounds like the hospital failed to do valid utilization review Jump through hoops and touch their nose like Simon Says.

[hinckley buzzard]

Yes this was an oversight. She needed to be admitted for treatment by her doctor and he neglected or forgot to sign the order.

[Cyman]

Since adopting Dr Hsiu’s middle 80’s MediCare’s hospital payment reform plan known as DRGs, hospitalization of patients has gone to 95% clerical and 5% medical care.

And it will only get worse.

[386wt]

They tried the same thing with my elderly Mom at a local hospital. Had her in with a double broken leg after a fall and classified her as "observation" for six days.

They backed off and corrected their mistake after I threatened to get an attorney involved. The hospitalist even accused me of trying to get medicare to pay for her long term care. It turned out that she required well over two months skilled care. Which thank God medicare covered.

I often wonder what hospital internal communications would tell us about this practice? My guess is that it is widespread across the USA.

[fruser1]

This is part of the problem of third-party-payer in general.

Since all cost “negotiation” first goes the insurance company, the patient is completely left out of the loop.

E.g., if the hospitals indicated directly to the patient “We’ve treated your leg and that parts costs X dollars. Now, if you want to stay for observation, it’ll cost you Y dollars because it is not considered ‘in-patient’”.

Had the patients known this critical tidbit up front, they probably would’ve taken her home immediately after treatment, or, they would’ve at least known they’d have a bill coming and made a conscious decision to accept the cost.

[The Great RJ]

This must be common as my cousin’s 84 year old step Mom had the same issue after having back surgery. Again some paperwork snafu kept her from receiving Medicare paid home health care or a rehab stay in a nursing home.

[silverleaf]

He is retired military

MEDICARE (did she have part B?) should pay first, TRICARE any remaining

[Notary Sojac]

Medicare can bring (and has brought) criminal prosecutions against doctors and hospitals who bill a case as "inpatient" rather than "observation" when the documentation is not to Medicare's liking.

This is part of the war on "fraud and abuse".

[Notary Sojac]

There are plenty of doctors who in the past would gladly admit patients for three days of workups in order to qualify them for a Medicare skilled nursing stay.

This usually happened when a family caregiver told the doctor "Mom (or Grandpa) is just too much for me to handle...I'm breaking down under the strain"

Now, doctors face huge fines and jail time if they concoct a hospital stay of this kind. So naturally, they are erring in the opposite direction.